My name is [Your name]. I am currently [briefly outline your research relating to your request e.g. undertaking a project/ Masters / PhD / Professional Doctorate; Fellowship] at the [University or institution name].
I plan to release [state release type e.g. a report, article, dataset, final publication etc] of my research in [state the publication e.g. departmental publication; Journal of XXXX etc.]This publication will be available [state how the material will be accessible e.g.on the World Wide Web for public access; via paid subscription to a journal etc.
I wish to include the following copyright material in my publication and I believe you hold the copyright:
[description of material used e.g. diagram/illustration/photograph/(title or description of image, name of publication), etc.]
Which is in:
[description of the parent document. e.g. journal article (journal number, edition, volume, month, year); book (title, author, ISBN) etc.]
I am therefore requesting from you a permanent, royalty free, irrevocable, non-exclusive, worldwide licence to include these materials in my publication. Your material will be fully and correctly referenced.
If you do not own copyright in the material in question, I would be very grateful for any information you can provide as to who is the copyright owner.
I would appreciate confirmation that you hold copyright in the material stated above and your express licence to use the material in my publication. If you require any additional information, please do not hesitate to contact me. I can be reached at:
[Your contact information]