Games 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 *

Platforms *

Master Version Used *

Vocal/Instrumental *

Synopsis/Scene Description *

Context of Use ( Background, Featured Performance) *

Duration *

Media (Game, Website, Application, Other) *

Term *

Territory *

Project Number/UPC/ISBN *

Retail Price *

Release Date *

Date Date Picker Icon

Royalty Rate *

Number of Units Manufactured *

Advance based on Manufactured *

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.