Synchronization License Request Form
(For Advertisements)
Company Name
*
Company Street address
*
Street address line 2
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
*
Contact Phone number
*
Contact Email address
*
Contracting Party & Address (if different from Licensee)
Song Title
*
Writer(s) / Publisher(s)
*
Product
*
Context of Use (Background, Feature, Live Performance)
*
Master Version Used
*
Vocal/Instrumental
*
Storyboard
*
No. of Ads & Length
*
Territory
*
Term
*
Release Date
*
-
Month
-
Day
Year
Date
Clock Number / ISCI Code
Total Media Budget
*
Media
*
Option(s) to be exercised
*
Additional Notes/Comments:
Please remit online by pressing the "submit" button or Print and return by fax 615-386-3113 or email jennifer@wordsandmusicadmin.com. For questions please call 615-386-3102.
Submit
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