Print License Request Form
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)
*
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.
Select File
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.
Submit
Should be Empty: