COSMIC TRIGGER, INC.
Synch Licence Request
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Synchronization License Request
PLEASE READ Priority will be given to those forms that are easily legible and entirely filled in. Date of Request_________________Your Email_______________________________________________ Your
Name_________________________________Company Name_____________________________ Address______________________________________________________________________________ City_________________________________________State________Zip Code ____________________ Phone
#_______________________________________Fax #___________________________________ Type of
Request (check box) Motion Picture G Film Festival G TV G Video/DVD G Commercial AdvertisingG
Other_____________________________ Production Title__________________________________________________________________ Brief Synopsis__________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
_____________________________________________________________________________ Please
use additional paper if synopsis is longer than this Song Title____________________________________________________________________________ Writer(s)_____________________________________________________________________________ Publisher(s)________________________________________________________ ________________________________________________________________ Master / Re-recording / Cover Artist (Circle One) Artist______________________________________ Type
of Use (check one) _____ Background Vocal ______ Background
Instrumental ______ Visual Vocal ______ Visual Instrumental ______
Other__________________________ Number of Uses___________Duration of Use(s)________________________________________ Territory____________________________ Term____________________ Media_________________________ Scene Description of Use__________________________________________________________ ________________________________________________________ Proposed
Fee $_______________ Genre (Comedy, Drama, etc.)_________________________Budget________________________ Production Company _____________________________________________ Producer
______________________________ Writer _____________________________ Main Cast Members_______________________________Release
Date___________________ Once this form is complete please
mail to Cosmic Trigger, Inc. 217 East 86th St #151 New York,NY 10028
Or Fax to 212 262 6299 Please allow
10-14 business days to process your request before following up.
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