Surveypoint

Q1

Name of Copright Owner

First Name

Q2

Name of Copright Owner

Last Name

Q3

Address of Copyright Owner

Street Address

Q4

Address of Copyright Owner

Street Address Line 2

Q5

Address of Copyright Owner

City

Q6

Address of Copyright Owner

State / Province

Q7

Address of Copyright Owner

Postal / Zip Code

Q8

Name of Author

First Name

Q9

Name of Author

Last Name

Q10

Country of Citizenship of Author

Q11

Alien Certificate Number (if foreigner)

Q12

Job Title of Author

Q13

Classification of Work

Q14

If Modification Of a Previously Registered Copyright Work, State the New Matter

Q15

Date Completed

Date

Q16

Date First Printed/Reproduced

Date

Q17

City of Printing/Reproduction

Q18

Name of Publishing Company

Q19

Your capacity in this copyright application

Q20

Name

First Name

Q21

Name

Last Name

Q22

Signature

Q23

Date

Copyright Application Form -Form Fill

Name of Copright Owner

Name of Copright Owner

Address of Copyright Owner

Address of Copyright Owner

Address of Copyright Owner

Address of Copyright Owner

Address of Copyright Owner

Name of Author

Name of Author

Country of Citizenship of Author

Alien Certificate Number (if foreigner)

Job Title of Author

Classification of Work

If Modification Of a Previously Registered Copyright Work, State the New Matter

Date Completed

Date First Printed/Reproduced

City of Printing/Reproduction

Name of Publishing Company

Your capacity in this copyright application

Name

Name

Signature

Date