7/28/2019 Organization FormA

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Organization Form A: Image Use Permission Request 1/5 rev. Mar. 7, 2013

Form A 1/5

Image Use Permission Request

ApplicationName of organization

Address

Date YYYYMMDD

(a) Applicants nameYOUR NAMEYOUR NAME in katakana

Address

Affiliation

Title / Speciality

Telephone number with country code

Fax number with country code

E Email address

[Choose one] (1) (2)(b)

(c)

I am applying to obtain permission to reproduce an image of a work (b), that your

organization [Choose one](1) has used or published (2) holds in its collections, in mypublication (c) as detailed below.

(b) The name of the image and any other identifying information (where it is published, posted,held, etc.)

[Highly recommended, if possible]

A copy of the work has been attached for identification purposes.

(c) Details of the planned publication1. AuthorYOUR NAME

7/28/2019 Organization FormA

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Organization Form A: Image Use Permission Request 2/5 rev. Mar. 7, 2013

Form A 2/52. /()

Title of the book, or titles of the paper/article and journal/anthology in which it will be

included (in the language of publication)

Japanese translation of the above titles

3. Genre(Check appropriate box(es))

Scholarly monographTextbookOther_________4. Publisher

Name and contact information of editor

5. Expected date of publication

6. Approximate number of pages

7. Expected readership(Check appropriate box(es))

Students/Researchers/specialistsGeneral public8. Sales region(Check appropriate box)

North AmericaNo regional limits9. Publication format(s)(Check appropriate box(es))

BookDigital publicationmedia Other

10.Number of copies to be published

11.Expected price

12. Image to be used(Check appropriate box(es))

ColorB&W Jacket1 Full-page size13. Notes[If applicable] likelihood of reprinting or expanded publication etc.

(d) In the event permission is granted(Check appropriate box(es))

1.

I would like to scan the image from the

7/28/2019 Organization FormA

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Organization Form A: Image Use Permission Request 3/5 rev. Mar. 7, 2013

Form A 3/5following publication TITLE OF PUBLICATION

URL WEB ADDRESS

I would like to download the image from the above Web page.

I would like to request a publication-quality image(Check appropriate box(es))

Color Black and whiteDigital image Desired file format

/ Transparency / duplicate Photographic print2. I would appreciate the image by YYYYMMDD

End of Application

PermissionDate (YYYY/MM/DD)

[Date of request] YYYYMMDD(a) YOUR NAME in

katakana (b)(c)

This is to grant (a) YOUR NAME permission to reproduce an image used/held byour organization (b), in the publication (c), as described above and requested on DATE OF

REQUEST .

Name of organization

Above name in English or romaji

Address in romaji

Name of relevant department

Above name in English or romaji

Contact person

Above name in romaji

Signature of legal representative of organization

7/28/2019 Organization FormA

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Organization Form A: Image Use Permission Request 4/5 rev. Mar. 7, 2013

Form A 4/5 Above name in romaji

* * * * * * * * * *

V

The conditions below must be observed. (Check appropriate box(es))

The publication must include that the image is being used with our organizationspermission.

Please send us _____copies of the publication.

Other conditions (This may be in Japanese)

VImage to be used (Check appropriate box(es))

Scan image from the following publication (Specify publication in Japanese and romaji)

URL

Download image from the above Web page.

A publication-quality image will be provided according to the

following conditions

Color Black and white Digital image File format Transparency Photographic print

7/28/2019 Organization FormA

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Organization Form A: Image Use Permission Request 5/5 rev. Mar. 7, 2013

Form A 5/5

The image is enclosed.

[]

___________[]

Further action is needed to obtain the image; contact the above person with a copy of

this permission.

Please return the image after use.

End of Permission