COPYRIGHT PERMISSION REQUEST FORM

Date : 　　　　　　　　

To : 					From : 
The Chemical Society of Japan		 Name : 					
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Tokyo 101-8307, Japan			 						
E-mail: tensai@chemistry.or.jp		 Address : 					
Phone: +81-3-3292-6161			 						
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I am preparing the following paper/book.
•	Paper/Book title : 									
											
•	Name of the publication : 								
											
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•	The purpose of this request (select from the following) :
[Journal/Book] [Thesis] [Repository] [Textbooks / Lectures / Exam questions]
[The periodic table with atomic number]							
[Others] : 										
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I request your permission to reproduce the following material.
•	Paper/Book title : 									
											
•	Name of the publication (select from the following) :
[Chemistry Letters][Bulletin of the Chemical Society of Japan][Chemistry & Chemical Industry]
[Chemistry & Education]
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•	Author(s)/Editor(s) : 									
											
•	Year : 		Vol. :     	 	No. : 	         	
•	Page(s) : 			Figure(s)/Table(s) : 					
•	   I need a permission with signature.

We hereby grant permission for the reuse of the material requested above.

Shin-ichi Suzuki					Date : 					
Secretary-general
The Chemical Society of Japan			Our Ref. No. CY-RT