Mechanical Rights Form

							MECHANICAL RIGHTS NOTIFICATION                  [FORM 1.D.2009]

APPLICANT(S):

NAME

NAME

NAME


TITLE OF NEW WORK

REQUESTED SONG TITLE

ARTIST/COMPOSER

PUBLISHER

FILE NUMBER

AMOUNT/TIME OF PORTION TO BE USED         min         sec

DESCRIBE PORTION OF SONG TO BE USED IN NEW WORK:




SIGNATURE

SIGNATURE

SIGNATURE

SIGNATURE




FORM 1.D.2009 – Page 1 of 1