Synchronization License Request Form (For Advertisements)

Company Name *

Company Street address *

Street address line 2

City *

State *

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 *

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.