Fill and Sign the Have a Question About the Single Application Form

USE THIS FORM IF— 1. You are the only author and copyright owner of this work, and 2. The work was not made for hire, and 3. The work is completely new (does not contain a substantial amount of material that has been previously published or reg- istered or is in the public domain) and is not an audiovisual work. If any of the above does not apply, you must use standard Form PA. NOTE: Short Form PA is not appropriate for an anonymous author who does not wish to reveal his or her identity and may not be used for audiovisual works, including motion pictures. HOW TO COMPLETE SHORT FORM PA à Type or print in black ink. à Be clear and legible. (Your certificate of registration will be copied from your form.) à Give only the information requested . NOTE: You may use a continuation sheet (Form __/CON) to list individual titles in a collection. Complete Space A and list the individual titles under Space C on the back page. Space B is not applicable to short forms. Instructions for Short Form PA For works of the performing arts (except audiovisual works) Title of This Work You must give a title. If there is no title, state “UNTITLED.” Alterna- tive title: If the work is known by two titles, you also may give the second title. Or if the work has been published as part of a larger work, give the title of that larger work, in addition to the title of the contribution. If you are registering an unpublished collection, give the collection title you want to appear in our records (for example: “Songs by Alice, Volume 1”). Be sure to keep a personal record of the songs you have included in the collection. If you want the certificate of registration to list the individual titles as well as the collection title, use a continuation sheet (Form___/CON). Name and Address of Author and Owner of the Copyright Give your name and mailing address. You may include your pseud- onym followed by “pseud.” Also, give the nation of which you are a citizen or where you have your domicile (i.e., permanent residence). Please give daytime phone and fax numbers and email address, if available. Year of Creation Give the latest year in which you completed the work you are register- ing at this time. A work is “created” when it is written down, recorded, or otherwise “fixed” in a tang ible form. Publication If the work has been published (i.e., if copies have been distributed to the public), give the complete date of publication (month, day, and year) and the nation where the publication first took place. Type of Authorship in This Work Check the box or boxes that describe the kind of material you are registering. Check only the authorship included in the copy, tape, or CD you are sending with the application. For example, if you are registering lyrics and plan to add music later, check only the box for “lyrics.” Signature of Author Sign the application in black ink and check the appropriate box. The person signing the application should be the author or his/her authorized agent. Person to Contact for Rights and Permissions This space is optional. You may give the name and address of the per- son or organization to contact for permission to use the work. You may also provide phone, fax, or email information. Certificate Will Be Mailed This space must be completed. Your certificate of registration will be mailed in a window envelope to this address. Also, if the Copyright Office needs to contact you, we will write to this address. Deposit Account PRIVACY ACT ADVISORY STATEMENT Required by the Privacy Act of 1974 (P.L. 93-579) The authority for requesting this information is title 17 U.S.C., secs. 409 and 410. Fur nishing the requested information is voluntary. But if the information is not furnished, it may be necessary to delay or refuse registration and you may not be entitled to certain relief, remedies, and benefits provided in chapters 4 and 5 of title 17 U.S.C. The principal uses of the requested information are the establishment and maintenance of a public record and the examination of the application for compliance with the registration requirements of thecopyright law. Other routine uses include public inspection and copying, preparation of public indexes, prepara- tion of public catalogs of copyright registrations, and preparation of search reports upon request. NOTE: No other advisory statement will be given in connection with this application. Please keep this statement and refer to it if we communicate with you regarding this application. MAIL WITH THE FORM— à A $30 (effective through June 30, 2002) filing fee in the form of a check or money order (no cash) payable to “Register of Copyrights,” and à One or two copies of the work. If the work is unpublished, send one copy, tape, or CD. If published, send two copies of the best published edition if the work is in printed form, such as sheet music, or one copy of the best published edition if the work is recorded on a tape or disk.Note: Inquire about special requirements for works first published outside the United States or before 1978. Copies submitted become the property of the U.S. Government. Mail everything (application form, copy or copies, and fee) in one package to: Library of Congress, Copyright Office 101 Independence Avenue, S.E. Washington, D.C. 20559-6000 QUESTIONS? Call (202) 707-3000 [TTY: (202) 707-6737] be- tween 8:30 a.m. and 5:00 p.m. eastern time, Monday through Friday except federal holidays. For forms and informational circulars, call (202) 707-9100 24 hours a day, 7 days a week, or download them from the Internet at www.loc.gov/copyright. Se- lected informational circulars but not forms are available from Fax-on-Demand at (202) 707-2600. Complete this space only if you currently maintain a deposit account in the Copyright Office. 1 2 3 4 5 6 7 8 9 Title of This Work: Alternative title or title of larger work in which this work was published: Name and Address of Author and Owner of theCopyright: Year of Creation: If work has been published, Date and Nation ofPublication: Type of Authorship in This Work: Check all that this author created. Signature: (Registration cannot be completed without a signature.) Name and Address of Person to Contact forRights and Permissions: Phone, fax, and email: Complete this space only if you currently hold a Deposit Account in the Copyright Office. Phone ( ) Fax ( ) a. Date ___________________________________ ____________ _________________ Month Day Year b. Nation ❑ Music ❑ Other text (includes dramas, screenplays, etc.) ❑ Lyrics I certify that the statements made by me in this application are correct to the best of my knowledge.* Check one: ❑ Author ❑ Authorized agent ❑ Check here if same as #2 above. Phone ( ) Fax ( ) Email: For a Work of the Performing Arts UNITED STATES COPYRIGHT OFFICE Registration Number PA PAU Effective Date of Registration Application Received Deposit Received One Two Fee Received SHORT FORM PA Name