Fill and Sign the Sample Associate Form

Print Form Clear Form APPLICATION FOR COPYRIGHT REGISTRATION * Designates Required Fields 1WORK BEING REGISTERED 1a. * Type of work being registered (Fill in one only) Literary work Performing arts work Visual arts work Motion picture/audiovisual work Sound recording Single serial issue ApplicationForCopyrightRegistration 1b. * Title of this work (one title per space) Remove WorkTitles Click here to create space to add an additional title 1c. For a serial issue: Volume Issue Number Frequency of publication: ISSN Other 1d. Previous or alternative title 1e. * Year of completion Publication (If this work has not been published, skip to section 2) (mm/dd/yyyy) 1f. Date of publication 1h. Nation of publication United States Other 1g. ISBN Clear Response Other 1i. Published as a contribution in a larger work entitled 1j. If line 1i above names a serial issue Volume Number Issue On pages 1k. If work was preregistered Number PRE- Privacy Act Notice Sections 408-410 of title 17 of the United States Code authorize the Copyright Office to collect the personally identifying information requested on this form in order to process the application for copyright registration. By providing this information you are agreeing to routine uses of the information that include publication to give legal notice of your copyright claim as required by 17 U.S.C. § 705. It will appear in the Office’s online catalog. If you do not provide the information requested, registration may be refused or delayed, and you may not be entitled to certain relief, remedies, and benefits under the copyright law. Page of Print Form Clear Form For Office Use Only WorkBeingRegistered 2 AUTHOR INFORMATION - Entry Number 2a. Personal name Remove Item * complete either 2a or 2b First Name Middle Last 2b. Organization name 2c. Doing business as 2d. Year of birth 2f. * 2e. Year of death Citizenship United States Other Other Clear Domicile United States Other Other Clear Made for hire Anonymous Pseudonymous 2g. Author's contribution: (Pseudonym is: Continuation of Author Information 2h. * This author created (Fill in only the authorship that applies to this author) Text/poetry Compilation Map/technical drawing Music Editing Sculpture Architectural work Lyrics Computer program Jewelry design Photography Motion picture/audiovisual Collective work 2-dimensional artwork Script/play/screenplay Sound recording/performance Other: For Office Use Only AuthorInformation Privacy Act Notice Sections 408-410 of title 17 of the United States Code authorize the Copyright Office to collect the personally identifying information requested on this form in order to process the application for copyright registration. By providing this information you are agreeing to routine uses of the information that include publication to give legal notice of your copyright claim as required by 17 U.S.C. § 705. It will appear in the Office’s online catalog. If you do not provide the information requested, registration may be refused or delayed, and you may not be entitled to certain relief, remedies, and benefits under the copyright law. Page of Print Form Clear Form Click here to create space to add an additional author 3 COPYRIGHT CLAIMANT INFORMATION Claimant Remove Item - Entry Number Clear Section * complete either 3a or 3b - If you do not know the address for a claimant, enter "not known" in the Street address and City fields. 3a. Personal name First Name Middle Last 3b. Organization name 3c. Doing business as 3d. Street address * Street address (line 2) City * State Email ZIP / Postal code Phone number 3e. If claimant is not an author, copyright ownership acquired by: Country (Add "+" and country code for foreign numbers) Written agreement Will or inheritance Other Clear Other For Office Use Only CopyrightClaimantInformation Click here to create space to add an additional claimant 4 LIMITATION OF COPYRIGHT CLAIM Skip section 4 if this work is all new. 4a. Material excluded from this claim (Material previously registered, previously published, or not owned by this claimant) Text Artwork Music Sound recording/performance Motion picture/audiovisual Other: Privacy Act Notice Sections 408-410 of title 17 of the United States Code authorize the Copyright Office to collect the personally identifying information requested on this form in order to process the application for copyright registration. By providing this information you are agreeing to routine uses of the information that include publication to give legal notice of your copyright claim as required by 17 U.S.C. § 705. It will appear in the Office’s online catalog. If you do not provide the information requested, registration may be refused or delayed, and you may not be entitled to certain relief, remedies, and benefits under the copyright law. Page of Print Form Clear Form 4b. Previous registration(s) Number Year Number Year 4c. New material included in this claim (This work contains new, additional, or revised material) Text Compilation Map/technical drawing Music Poetry Sculpture Architectural work Lyrics Computer program Jewelry design Photography Motion picture/audiovisual Editing 2-dimensional artwork Script/play/screenplay Sound recording/performance Other: For Office Use Only LimitationOfCopyrightClaim 5 RIGHTS AND PERMISSIONS CONTACT Clear Section Check if information below should be copied from the first copyright claimant First Name Middle Last Name of organization Street address Street address (line 2) City Email State ZIP / Postal code Country Phone number (Add "+" and country code for foreign numbers) Privacy Act Notice Sections 408-410 of title 17 of the United States Code authorize the Copyright Office to collect the personally identifying information requested on this form in order to process the application for copyright registration. By providing this information you are agreeing to routine uses of the information that include publication to give legal notice of your copyright claim as required by 17 U.S.C. § 705. It will appear in the Office’s online catalog. If you do not provide the information requested, registration may be refused or delayed, and you may not be entitled to certain relief, remedies, and benefits under the copyright law. Page of Print Form Clear Form For Office Use Only RightsAndPermissionsContact 6 CORRESPONDENCE CONTACT Copy from first copyright claimant Copy from rights and permissions contact First name * Middle Last * Name of organization Street address * Street address (line 2) City * State ZIP / Postal code Email * Daytime phone number Country (Add "+" and country code for foreign numbers) For Office Use Only CorrespondenceContact 7 MAIL CERTIFICATE TO: * Complete either 7a, 7b, or both Copy from first copyright claimant 7a. First Name Copy from rights and permissions contact Middle Copy from correspondence contact Last Privacy Act Notice Sections 408-410 of title 17 of the United States Code authorize the Copyright Office to collect the personally identifying information requested on this form in order to process the application for copyright registration. By providing this information you are agreeing to routine uses of the information that include publication to give legal notice of your copyright claim as required by 17 U.S.C. § 705. It will appear in the Office’s online catalog. If you do not provide the information requested, registration may be refused or delayed, and you may not be entitled to certain relief, remedies, and benefits under the copyright law. Page of Print Form Clear Form 7b. Name of organization 7c. Street address * Street address (line 2) City * State ZIP / Postal code Country For Office Use Only MailCertificateTo 8 CERTIFICATION 17 U.S.C. § 506(e): Any person who knowingly makes a false representation of a material fact in the application for copyright registration provided for by section 409, or in any written statement filed in connection with the application, shall be fined not more than $2,500. I certify that I am the author, copyright claimant, or owner of exclusive rights, or the authorized agent of the author, copyright claimant, or owner of exclusive rights, of this work, and that the information given in this application is correct to the best of my knowledge. 8a. Handwritten signature Today's date 8b. Printed name 8d. Deposit account number Write date by hand 8c. Date signed Account holder 8e. Applicant's internal tracking number (optional) Privacy Act Notice Sections 408-410 of title 17 of the United States Code authorize the Copyright Office to collect the personally identifying information requested on this form in order to process the application for copyright registration. By providing this information you are agreeing to routine uses of the information that include publication to give legal notice of your copyright claim as required by 17 U.S.C. § 705. It will appear in the Office’s online catalog. If you do not provide the information requested, registration may be refused or delayed, and you may not be entitled to certain relief, remedies, and benefits under the copyright law. Page of Print Form Clear Form For Office Use Only Certification Privacy Act Notice Sections 408-410 of title 17 of the United States Code authorize the Copyright Office to collect the personally identifying information requested on this form in order to process the application for copyright registration. By providing this information you are agreeing to routine uses of the information that include publication to give legal notice of your copyright claim as required by 17 U.S.C. § 705. It will appear in the Office’s online catalog. If you do not provide the information requested, registration may be refused or delayed, and you may not be entitled to certain relief, remedies, and benefits under the copyright law. Page of