Contact Name *
Email Address *
Company / Organization Name *
Address Line 1 *
Address Line 2
City *
State / Province
Zip / Postal Code
Country *
Crossroad Title *
Author *
ISBN *
Excerpt Type * Select TypeTextImageTableOther
Portion Requested *
Word Count (if text excerpt — please specify; under 3,000 words)
Format * Select FormatBookJournalArticleWebsiteOther — please specify
Title of New Publication / Project *
Publisher / Institution *
Language(s) *
Territory / Distribution Area *
Estimated Print Run (copies)
Estimated Retail Price (USD, if applicable)
Digital Use * YesNo
One-time use or multiple editions? * One-time useMultiple editions
Print / Digital / Both * PrintDigitalBoth
Requested Permission Term (years) *
Website URL (if applicable)
Additional Notes or Explanation of Use
I confirm that the information provided is accurate and complete.
Signature / Name *
Date *
