PERMISSIONS INFORMATION

Permission Request Form for Republication of FIGURES and TABLES

Requestor Contact Information:
Date Permission Needed
Prefix (Mr, Ms, Dr)
First Name
Last Name
Organization Name
Department
Street Address
Street Address	(optional)
City
State/Province
Zip or Postal Code
Country
Direct Telephone Number
Fax Number
Check here if you require an original document to be sent by mail:
	Mail
*E-mail Address
Please tell us how the borrowed material will be used. Complete all boxes in Section A or B
Section A - republication in a textbook or journal.
Title of your Publication
Title of Chapter/ Issue/Section
Author
Editor
Publisher
Edition
Year of Publication
Your Reference or Job Number	(optional)
List all languages for which you wish rights
Format
Additional Information

Section B - monographs, slide kits, supplements, etc.
Describe your intended use of NEJM content
Intended Audience
Sponsor
Date of Use
Your Reference or Job Number	(optional)
List all languages for which you wish rights
Format
Additional Information


Please complete the following information about the NEJM material you wish to borrow.
Select "Adapted" if you are making any substantive change to the original figure/table. Font and style changes are not considered substantive. A copy of your revised figure/table must be attached to receive permission. Do not attach a file if you are not making changes. If you do not have an electronic version of your adapted image, complete the form and select "Option 3" on the next page.

Please note:

The "Remove" option will delete the data row. The "Reset" option will erase the data from the entire permission request.

Comments and questions? Please contact us.