Please complete this form with all relevant information.

Invoice To:		License To:
Date		Date
Attention		Attention
Phone Number		Phone Number
Best Time To Be Reached		Best Time To Be Reached
Fax		Fax
E-mail		E-mail
P.O.#

Clearance License Categories  (Check all that apply:)

Broadcast Production  Local  (US & Canada only)  TV Radio Regional  (US & Canada only)  TV Radio Network  (US & Canada only)  TV Radio Network  (Worldwide)  TV Radio Program Local TV Radio Syndicated or Network TV Radio Infomercial TV Radio Internet (On-line Productions) TV Radio Common Carrier (planes, etc.) All Broadcast Rights (TV & Basic Cable, Satellite, Premium Cable & Production for Sale to the General Public up to 10,000 copies.) All Non-Theatrical Rights (Non-broadcast, Educational, Government, Corporate non-broadcast) Premium Cable Production (HBO, Disney Channel, Showtime, etc.) Cable Network Origination Promotional Spot (includes PSA's) Promo Spot (US & Canada Only) Promo Spot (Worldwide) Pay-Per View Program Cable Film

Production for Sale in Limited Market (Corporate, Industrial, Sales, etc.) Audio Cassette or CD Video Cassette or DVD Multimedia Hard Disc (non-interactive) Distribution over 10,000 copies Retail Sales (General Public) Audio Cassette or CD Video Cassette or DVD Multimedia Hard Disc (non-interactive) Distribution over 10,000 copies Audio Visual Production Non- Broadcast (Audio or Video Cassette/Disc, Slides Film or Multimedia Hard Disc. Non-Interactive Production) Up to 500 copies of production Up to 10,000 copies of production Multimedia Production Interactive (Non-Linear) Production - (CD-ROM or Hard Disc) Production NOT for Sale Production for Sale (Limited Market) Production for Sale (Retail) Total # minutes in source file Theatrical Production Trailer or Commercial Trailer or Commercial (All Rights) Film  (Theater Release Only) Film  (All Rights) Festival/Theme Park Rights Distribution > 10,000 copies

Production Info. Territory Product Production Title/URL Air Date(s) Length Min. Sec. Ad Agency ISCI# Station(s) 1st Line of Copy Misc./Comments City, State Regional National (US/Canada) Worldwide Cue Sheet Codes (use below if applicable)        BI: Background Instrumental VI: Visual Instrumental EE: Logo BV: Background Vocal VV: Visual Vocal TO: Theme Open TC: Theme Close

Tracks    Song Title CD-Track# BMI # # 0f Uses Cue Sheet Codes (see above definitions) 1 2 3 4 5

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