Print License Request


Print License Request

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PLEASE READ
Priority will be given to those forms that are easily legible and entirely filled in.
 
Requestor Information
 
Your Name_________________________________________________ Date of Request______________
 
Company/Organization/School Name_______________________________________________________
 
Address_______________________________________________________________________________
 
City_______________________________________State__________Zip Code_____________________
 
Phone #___________________________________Fax #_______________________________________
 
Email_________________________________________________________________________________
 
 
Information About Your Publication
Is This A...(check one)
 
____ New Arrangement
____ Lyric Reprint Music Reprint

Publisher______________________________________________________________________________
 
Name of publication____________________________________________________________________
 
Author(s)/Arranger(s)____________________________________________Territory_______________
 
Item Number____________________Date of Publication________________Price___________________
 
Language______________________Number of Songs_________________Term__________________
 
Synopsis of publication___________________________________________________________________
 
________________________________________________________________________________________
 
WE MUST HAVE ALL PAGES WITH THE ACTUAL USAGE IN CONTEXT (BOTH PRIOR
 
AND FOLLOWING PAGES) BEFORE WE CAN EVEN CONSIDER ISSUING A LICENSE.
 
Type of publication (check one)
 
___  Book 
___  Folio
___  Sheet MusicG
___  Magazine/Other Subscription *
___  Liner Notes
___  Poster
___  Other_____________________
 
*if magazine or other subscription please fill out the following section
 
Circulation_______________________________Number of measures used (for music reprint)________
 
Information About The Song You Wish To Use
 
Title(s)_________________________________________________________________________________
 
Writer(s)______________________________________________________________________________
 
Publisher(s)_____________________________________________________________________________
 
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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1202 Lexington Ave #217 
New York, NY 10028
646 438 2690

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