MPCA COMMERCIAL SYNCHRONIZATION LICENSE REQUEST FORM

 

Advertising Agency:                       _______________________________________

 

Contact Name:                     _____________________________________________

 

Address:                                _____________________________________________

 

                                                _____________________________________________

 

Phone Number:                   (___) _____ - ____________

 

Fax Number:                         (___) _____ - ______________

 

Email:                                      _____________________________________

 

 

Licensee Name:                    ___________________________________

 

Product:                                ___________________________________

 

 

SONG TITLE:            ____________________________________________________

 

Writers:                     ____________________________________________________

 

 

Master Recording or Re-Recording?

If Master, please list original artist: ____________________________________________

 

Use:                            Background ____     Visual ____

Format:                      Vocal ____                 Instrumental _____

 

Timing of Song:      ___________

 

Length of Spot:        ___________

 

Media (TV, radio, cable, etc) List all that apply:

 

                                    _________________________________________________________

 

                                    _________________________________________________________

 

 

Territory:                  ___________________________________

 

Term:                         ___________________________________

 

Start Date:                 ___________________________________

 

Number of spots/lifts:       _____________________________

 

 

Script / Storyboard available?     Yes ____ No ____

If yes, please attach and send the synopsis and/or description to your request.

 

 

Options requested: _____________________________________________________

 

_______________________________________________________________________

 

 

Exclusivity?               YES ____ NO ____

 

Parody lyrics?          YES ____ NO ____

If yes, please attach new lyrics to your request if currently available.

 

 

Production/Music budget: _________________________

 

 

Comments:

 

________________________________________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

________________________________________________________________________

 

 

Thank you for our interest in this MPCA Song.

Please complete this form and fax it, along with any additional elements

(i.e. film synopsis, parody lyrics)

to the following number:

 

MPCA FAX:

(212) 796-2031

 

We will be in touch with you.

 

MUSIC PUBLISHING COMPANY OF AMERICA ≠ IT ALL STARTS WITH A SONG.