Sample Clearance Services

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