Print 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 *
Term *
Territory *
Release Date *

- Month - Day Year
Date
Other Songs in Project *
Retail Price *
Project Number/UPC/ISBN *
Media *
Royalty Rate *
Number of Units Manufactured *
Advance based on Manufactured *
Digital Release?

Yes
Estimated Digital Sales
Additional Notes/Comments:
If lyric reprint use, please attach the excerpt as it is to appear in your publication, including one page before and after the excerpt.

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Cancel of
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.
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