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.
