Sample Clearance Request Form
 Complete the form with as many details as possible

Enter information by clicking in boxes



1. Original Work

 

 

 

Title of original work:

Writer(s) of original work:

Publisher(s) of original work:

Territory:

Original artist:

Original record company:

Brief description of original
work within new work:


2. New Work

 

Title of new work:

Does it contain any other samples? (which) :

Writer(s) of new work:

Publisher of new work:

Artist:


3. Proposed Release Information

 

Label and Catalogue Number:

Distribution:

Format (album / single):

Proposed release date:

Territory of release / required for clearance:

Intended units of manufacture:


4. Label Contact

 

Name:

Company:

Address:

Phone number:

Fax number:

Mobile number:

Email address:


5. Party Responsible for Payment (if different from above)

 

Name:

Company:

Address:

Phone number:

Fax number:

Mobile number:

Email address:


6. Any further information we may find useful