Fill and Sign the Request for Permission to Arrange a Musical Composition Form

REQUEST FOR PERMISSION TO ARRANGE PART 1. To be completed by party requesting permission: I/We are requesting permission and non-exclusive license to arrange a musical composition to which you hold the copyright (hereinafter referred to as “The Arrangement”). Please complete Part 2 of this form and return it in the enclosed self- addressed stamped envelope. If you request the remittance of any money and if the conditions are agreeable, I/we shall do so upon receipt of Part 2 of this form. Thank you for your consideration of this request. 1. To:       Date:       (Name of publisher) 2. Address:       City       State       Zip:       3. Title of Composition:       By:       (Words)       (Music) 4. The Arrangement will be for       (Type of Arrangement) in       (Number of instrumental and/or vocal parts) We will produce       copies of the Arrangement for exclusive use and performance by our       (Teachers, students, members etc.)       Name of Institution ________________________       Signature Date       Title - 1 – Copyright 2004 USLegalforms.com PART 2. 1. Permission: Granted Denied Reason:       (Process in publication, available for sale, etc.) 2. We will require a fee of $       in exchange for granting you permission as requested to arrange the aforementioned piece of music. 3. All copies of The Arrangement shall bear the following copyright notice:       and the words “arranged by permission” on the bottom of the first page of music of each part of The Arrangement. A copy of The Arrangement shall be furnished to you upon completion. 4. Additional Provisions:       The license agreement constitutes the entire understanding between the two aforementioned parties and may not be modified or amended except by written agreement signed by both parties. This is a limited use license, limited to the specific use as identified in Part 1. Permission granted: ________________________       Signature Date       Title - 2 – Copyright 2004 USLegalforms.com