Copyright Application Form

Copyright Application Form
Name of Copright Owner
First NameLast Name
Address of Copyright Owner
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Name of Author
First NameLast Name
Country of Citizenship of Author
Alien Certificate Number (if foreigner)
Job Title of Author
As appears in the title page of the work
Classification of Work
If Modification Of a Previously Registered Copyright Work, State the New Matter
Indicate the chapters by numbers, including the pages, and material alterations
Date Completed
MonthDayYear
Date
Date First Printed/Reproduced
MonthDayYear
Date
City of Printing/Reproduction
City where the work was printed/reproduced
Name of Publishing Company
Price of Copies for Sale
Your capacity in this copyright application
I, hereby depose, being duly sworn in accordance with the law, affirm and declare that the information provided above is true and correct to the best of m knowledge. I am submitting this application with full knowledge and understanding that the outcome of this application shall bind me by the laws of the state that confers jurisdiction over this copyright application.
Name
First NameLast Name
Signature
Clear
Date
MonthDayYear
Date
Should be Empty: