Synchronization License Request Form
(For TV/Film)
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)
*
Master Version Used
*
Vocal/Instrumental
*
Program/Film/Project Title
*
Production Company
*
Synopsis of Program/Film/Project (include other songs used)
*
Director
*
Producer
*
Distributor
*
Duration of Use
*
Total Program/Film/Project Budget
*
Program/Film/Project Music Budget
*
Scene Description
*
Cast
*
Context of Use
*
Background Music/Incidental Music
Title Music (over opening or closing credits)
Featured Usage
Out-of-Context Trailers
Other
Media
*
Television Broadcast
Internet (streaming and/or downloadable)
Videogram cassettee for retail sale and./or rental solely for home viewing (DVD, Blu Ray, Other)
Theatrical Exhibition
Film Festivals
DVD Extras / "Making of"s"
In-Context Trailers
Out-of Context Trailers
Other
If Television, please specify: Free, Cable, Pay, Satellite, VOD, All
If Internet, please specify : All Internet or Limited Websites
Release Date
*
-
Month
-
Day
Year
Date
Term
*
Territory
*
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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