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MPCA
TELEVISION SYNCHRONIZATION
LICENSE REQUEST FORM |
Licensee Name: ________________________________________________________________
Contact Name:
________________________________________________________________
Address:
________________________________________________________________
________________________________________________________________
Phone Number: (___) _____ - ______________
Fax Number: (___)
_____ - ______________
Email:
__________________________________________
SONG TITLE:
__________________________________________
Writers:
__________________________________________
Master
Recording or RE-record?
If
Master, please list artist: ____________________________________
Production
Title: __________________________________________
Type
of Production __________________________________________
Synopsis
/ Scene Description available?
Yes ____ No ____
If
YES, please attach the synopsis and/or description to your request.
Notable
actors/directors involved with and/or attached to project:
______________________________________________________________________
______________________________________________________________________
Type
of use: End Title
____
Main Title
____
Background ____
Visual Vocal ____
Vocal
____ or Instrumental _______
Length
of song to be used: ____________________________________________
Media (TV, Cable, Video etc.), list all that apply:
_____________________________________________________________
On what station will
the production initially air? _______________________________
At what time will the
production initially air? _______________________________
Territory: _____________________________________
Term:
_____________________________________
Start Date:
_____________________________________
Options
requested: ________________________________________________________________
___________________________________________________________________________________
Parody lyrics? Y / N
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.