Synchronization License Request Form
(For Advertisements)
Company Name
*
Company Street address
*
Street address line 2
City
*
State
*
Please Select
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
2 digit month, 2 digit day, 4 digit 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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