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LICENSE REQUEST FORM
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* Indicates required question
Request a License for: (mark as many as apply):
*
Mechanical/DPD (cds, USB flash drives, vinyl, mp3 downloads, etc)
Video (DVD)
Other:
Required
SONG INFORMATION
Song Title
*
Your answer
Songwriter(s)
*
Your answer
CONTACT INFORMATION
(Person Completing Form)
Full Name
*
Your answer
Phone Number (no spaces, no dashes)
*
Your answer
Email
*
Your answer
LICENSEE INFORMATION
(Person, Company, or Organization responsible for Royalty Payment, and
whose name and contact information should appear on the license)
Name (Individual, Company/Org)
*
Your answer
Address
*
Your answer
Phone (no spaces, no dashes)
*
Your answer
Email
*
Your answer
Website
Your answer
CDs: Number Of Units Manufactured. (500 unit minimum)
*
Your answer
Digital Downloads: If you will be making digital downloads available, estimate number of downloads you expect to sell. (100 unit minimum). If not making digital downloads available, enter zero.
*
Your answer
Flash Drive (Number Of Units Manufactured)
*
Your answer
Estimated Release Date
*
MM
/
DD
/
YYYY
Calculations are set by law at the current statutory rate of 12.7 cents per unit. Your license will be for the amounts submitted above. Please make contact again for any reorders.
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