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BOA Editions, Ltd. Contract for Permissions

Your Contact Information
Name:	Email:
Address:	Phone:
City:	Fax:
State:
Zip:

Tittle of poem(s) selected:
Title of book(s) from which Poem is selected:
Author:

If this request is for inclusion in book form, please fill out the following information:
Title of Work:	Price:
Type of Work: (e.g., anthology)	Binding:
Author / Editor:	Publication Date:
Publisher: If you are without a publisher at this point, please re-apply for permission when the publisher of your manuscript has been named.	Print Run: Rights: (e.g., North American, World, etc.)


If this request is for broadcast or website posting please fill out the following relevant information:
Type of Show:	Call Letters:
Type of Broadcast:	Web Address:
Name of Host:	Broadcast Date:
Company:


If this request is for a student packet, please fill out the following information:
Number of pages to be photocopied:	Instructor:
Number of packets to be printed:	Start of Term:
College or University:	Course Number:


For other kinds of permission requests, or to provide more details about information submitted above: