Work Registration Form Name First name * Last name * Email address * This is the email address of the person filling the form Work title * Alternate title Artiste * Duration (Mins and Secs) * Example 4.23 Release date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 Genre * Alternative Blues Calypso/Soca Country Dance Dance Hall Electronic Gospel Hip-Hop/Rap Jazz Latino Pop R&B/Soul Reggae Rock Spouge World PLEASE INDICATE WRITERS/PUBLISHERS NAMES AND SHARE OF ROYALTIES Name of Writer or PublisherDesignation (See description)Performing Share (%) This column MUST total 100%Mechanical Share (%) This column MUST total 100%IPI Number or Society of Co-writers, Composers or Publisher Writer/Publisher 1 - None -C for Composer (Music Only)A for Author (lyrics)CA for Composer and AuthorArr for Arranger of PDE for Original PublisherSE for Sub-Publisher Writer/Publisher 2 - None -C for Composer (Music Only)A for Author (lyrics)CA for Composer and AuthorArr for Arranger of PDE for Original PublisherSE for Sub-Publisher Writer/Publisher 3 - None -C for Composer (Music Only)A for Author (lyrics)CA for Composer and AuthorArr for Arranger of PDE for Original PublisherSE for Sub-Publisher Writer/Publisher 4 - None -C for Composer (Music Only)A for Author (lyrics)CA for Composer and AuthorArr for Arranger of PDE for Original PublisherSE for Sub-Publisher Writer/Publisher 5 - None -C for Composer (Music Only)A for Author (lyrics)CA for Composer and AuthorArr for Arranger of PDE for Original PublisherSE for Sub-Publisher Writer/Publisher 6 - None -C for Composer (Music Only)A for Author (lyrics)CA for Composer and AuthorArr for Arranger of PDE for Original PublisherSE for Sub-Publisher "C" for Composer (Music Only), "A" for Author (lyrics), "CA" for Composer and Author, "Arr" for Arranger of PD, "E" for Original Publisher, "SE" for Sub-Publisher | "Performing" column MUST total 100% | "Mechanical" column MUST total 100% Any other information you need to tell us? Tick Box For purpose if otherwise of registration Amended Registration Dramatical Musical Work Authority not given for First recording Tick Box for Preferred US Licensing Society * ASCAP BMI SESAC Publishing: Date of Agreement Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2012201320142015201620172018201920202021202220232024 Valid Thru Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201220132014201520162017201820192020202120222023202420252026202720282029203020312032 Publishing Territory Attach Agreement Files must be less than 1 MB.Allowed file types: txt rtf pdf doc docx. Attach an MP3 copy of work * Send us an mp3 copy of the song.Files must be less than 20 MB.Allowed file types: mp3. IF BASED ON PUBLIC DOMAIN (PD) WORDS AND/OR MUSIC Title of PD work PD Writers Select One Arrangement of PD music and new words Adaption of PD words and new music Arrangement of PD music and adaption PD words Arrangement of PD music only (instrumental) Other If other (give details) IF AN AUTHORISED TRANSLATION OR AUTHORISED USE OF COPYRIGHT WORDS If includes (select one) A melody Sampling Please attach authorization Files must be less than 1 MB.Allowed file types: txt rtf pdf doc docx. Title of original work Original Writers