Synchronization License Request Form (For TV/Film)

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) *

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

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

If Television, please specify: Free, Cable, Pay, Satellite, VOD, All

If Internet, please specify : All Internet or Limited Websites

Release Date *

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.