Download the text version of the template here so you can replace the information in the parentheses to best reflect the video you are requesting permission for from the copyright holder. The template reads as follows:
To Whom It May Concern:
I use the video entitled, "(title)" in my course at San Jose State University. I have been teaching with it on a (VHS tape or DVD) from a copy purchased and owned by (me or the university). I am writing to you as the copyright holder or producer of this video to ask for your permission to digitize and upload it to the university's learning management system for my course. It would only be accessible by the students' login password to my class.
I hope to hear back from you soon. Thank you in advance for your response.