MPCA FILM SYNCHRONIZATION LICENSE REQUEST FORM

 

Licensee Name:        _______________________________________

 

Contact Name:         _______________________________________

 

Address:                    _______________________________________

 

                                    _______________________________________

 

 

Phone Number:       (___) _____ - ____________

 

Fax Number:             (___) _____ - ______________

 

Email:                          _______________________________________

 

 

SONG TITLE:            _______________________________________________

 

Writers:                     _______________________________________________

 

 

Master Recording or Re-Recording?

If Master, please list original artist: ____________________________________________

 

 

Production Title:     _________________________________________________________

 

Studio:                       _________________________________________________________

 

Distributor:             _________________________________________________________

 

Length of Film: ___________

Synopsis/scene description available? Y / N

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

 

Notable actors/directors involved with project: _________________________________

 

___________________________________________________________________________

 

 

Type of use. Please check all that apply:

End Title                   

Main Title                

Background

Visual Vocal

Other:         ___________________________________________

 

                      ________________________________________________

 

 

Proposed Timing/Length of Song use: ______________________

 

 

 

 

Media (Film Festivals, Theatrical etc.), list all that apply:

 

_________________________________________________________________

 

 

Territory: _____________________________________

 

Term: ________________________________________

 

Start Date: ____________________________________

 

Options requested: _____________________________________________________

 

_____________________________________________________

 

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.