Fill and Sign the Request Permission to Arrange Adapt Music for All Form

- 1 – Copyright 2004 USLegalforms.com 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 - 2 – 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 specifi c use as identified in Part 1. Permission granted: ________________________ Signature Date Title