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Copyright Questionnaire Form Author #1: Name: Citizenship: Date of Birth: Nature of author's contributions to the work: Author #2: Name: Citizenship: Date of Birth: Nature of author's contributions to the work: Was this work done anonymously or pseudonymously? Yes No Title of the work (include revision number): Any alternate titles of the work: Who owns the copyright in the work? If different from the author of the work, please explain how ownership was obtained (i.e. assignment, work for hire agreement). Applicant owns copyright as author is full-time employee and work was within scope of duties. Applicant owns copyright as author signed written agreement assigning rights to work. Other circumstance: Is your work based on any pre-existing material or does it include any pre-existing material? Yes No If yes, pre-existing material: Difference from your work: Has the material been published or publicly distributed? Yes No, If yes, date of first publication or earliest distribution: Nation of first publication or earliest distribution: Has this material, or an earlier version, been previously registered in the Copyright Office? Yes No If yes, please explain: Previous registration number: Year of previous registration: Nature of the work: Work of the performing arts (musical and dramatic works, pantomimes and choreographic works, motion pictures, and other audiovisual works, including computer program screen outputs). Sound recording. Work of the visual arts (paintings, sketches, drawings, sculptures, maps, photographs, scale models, jewelry designs, fabric designs, architectural design). Non-dramatic literary work (fiction, non-fiction, poetry, textbooks, reference works, directories, catalogs, advertising copy, compilations of information, computer program). If this work is a contribution to a periodical or collection of various works, please give the title of this individual contribution and the title of the collection as a whole: If a visual work, please check the following: Dimensional sculpture Dimensional artwork Reproduction of work of art Design on sheet-like material Map Photograph Jewelry design Technical drawing Text Architectural work. If an architectural work, has the building been constructed? Yes No For sound recordings, please complete the following: Selection Title Words Music Performance Sound Recording Original Work Please state whether others contributed to the creation of the work in any way. Name Address Phone Number Nature of Contribution Do you intend to pursue one or more foreign copyright applications for your invention? Yes No Do you wish to provide the Copyright Office with a license to make copies of this work for the blind and physically handicapped? Yes No Were you in a employment/hire relationship when you conceived, designed, developed, and/or reduced your materials to tangible form? Yes No If yes: Name and address of employer: Did your employer contributed in any manner at all to the development of this work? Yes No If yes, please describe: Did any materials contained in your copyright work come from your place of work? Yes No Did you sign any documents, agreements, or statements with your employer which restrict your use, ownership, or disclosure of copyright materials developed while in its employ? Yes No Were any governmental funds were used to develop this work? Yes No. If yes, please identify the governing agency, project identification information, sponsoring entity, and any other relevant information: Are you are under any oral or written obligation to assign, license, convey, or transfer any coypright, or any right you might possess in any copyright, covering this work to any other person, governmental agency, or business? Yes No. If yes, describe and provide name and address of entity obligated to: Any other information/concerns you’d like to be reviewed?