Date

Title of the work you would like to use.

Composer of Music

Author of Text (if any)

Exact duration of performance

Format of Recording
(Video, Film, DVD, etc.)

No. of copies to be manufactured

Country of Manufacture

In what countries will they be distributed
(Name of countries or Worldwide)

Production Company (Label)

Name and Title of Person Responsible
for Execution of this License

Full Street Address

Telephone No.

Fax No.

Web Site

E-mail Address