DVD License Request Form

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)*

Project Title*

Project Synopsis*

Master Version Used*

Vocal/Instrumental*

Scene Description*

Context of Use ( Background, Featured Performance)*

Duration*

Media (DVD, Blue Ray, other)*

Term*

Territory*

Digital Release?

yes

Required If Digital Release : ISRC Code

Project Number/UPC/ISBN*

Retail Price*

Release Date*

Date

Royalty Rate*

Number of Units Manufactured*

Advance based on Manufactured*

Number of Songs in Project*

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.