Your Full Name

Your Email Address

Song Title

Composer

Use Use Visual Vocal Featured Instrumental Background Instrumental Background Vocal Other

If Other, please describe

Timing

Licensee Organization Contact Name

Licensee Organization Contact Email

Licensee Organization Address

Licensee Organization Contact Phone #

Territory

Term

Air Date

Media - Include all requested media and scene description (TV, Film, Advertising, DVD, Other)

Production Budget

Music Budget

Requested Fee (100% prorated)

Options