Date
      

      From:

     Organization
       
     Requester's Name
    
     Title
    
      Phone Number      Fax Number        E-mail Address
        
   

    TO:

  IN RELIANCE UPON YOUR REPRESENTATION THAT YOU HAVE THE RIGHT TO LICENSE
  THE COMPOSITION LISTED BELOW PURSUANT TO THE COPYRIGHT LAW OF THE
  UNITED STATES OF AMERICA, WE ARE REQUESTING A MECHANICAL REPRODUCTION
  LICENSE COVERING THE FOLLOWING USE

    Song Title
   
     Writer
   
    Timing
   
    Percentage
   
    Rate
   
    Artist
   
    Record Number
   
    Configuration
   
    Album Title
   
    Release Date
   

   Signed:   O/B/O: