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.