Complete this form and deliver it to your acquisitions editor as soon as you have a complete MS that has been accepted for publication.

We need this information to ensure that copyrighted and archival materials are properly acknowledged in your book. Thank you for taking the time to supply complete and accurate answers. Please print out this sheet and write or type directly on it; attach additional sheets if necessary.

Signature

__________________________________

Date

_______________

MS title

________________________________________________________________

Have any portions of your MS been previously published?

Yes

    No

Have any portions of your MS or its accompanying art program been created or written by someone other than yourself?

Yes

    No

If you answered "yes" to either question, please complete the rest of this form. We will review this sheet when you return it to the Press, and either your acquisitions editor or an MS editor will alert you about which permissions to pursue. If you already have permissions letters for text or art for which you are certain you need permission, please attach legible photocopies of those letters to this form when returning it to your acquisitions editor. Make sure that each letter clearly indicates which piece of art or portion of text the permission represents (keep all original letters of permission for your files) and that you have photocopied the reverse sides if they contain any text.

Photocopies of ALL necessary letters of permission
must accompany the final version of your MS.

1. List all portions of this MS (text or art) that you have published before. Include complete bibliographic information.* Indicate for each (1) whether or not you retained copyright (if you retained copyright, provide photocopy of agreement) and (2) what percentage of the original work you present essentially unchanged in the current MS, and (3) the date of your contract with the previous publisher.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
2. List each text portion of your MS, published or unpublished, written by someone other than yourself. (Exclude brief prose quotations that you are certain fall within fair-use definitions.) Provide complete bibliographic information* for published materials; for unpublished materials, indicate repository, collection, and the like. In all cases, indicate the percentage of the total work (such as chapter, essay, novel, short story, diary, letter, interview) that you reproduce in your MS or, for poetry, number of lines quoted and number of lines in original.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
3. List each piece of art (line art, photographs, tables) created by someone other than yourself. For each table, indicate numbers of columns and rows. Provide complete bibliographic information* for published art. For unpublished art, provide complete information about source (repository, collection, etc.).

*Include author as on title page, article title, journal title, volume number, season or month, year, and page numbers for periodicals; author as on title page, book title, place of publication, publisher, year, and page numbers for portions of books.