Contact Name:

Address:

Phone Number:

Fax Number:

Email:

Song Title:

Licensee Name:

Production Title:

Studio

Distributor:

Length of Film/Show:

Release Date:

Timing of Song Use:

Background Visual

Use?:

Synopsis:

Scene description:

Vocal Instrumental

Timing of Song::

Media: i.e. film festivals, Demo reel, TV, etc.:

Territory of Distribution:

Term:

Start Date:

Options:

Exclusively?:

Parody Lyrics:

Questions or Comments: