Form in which Work was first incorporated in tangible form ("created"), e.g., photograph, lithographic print, etching, charcoal drawing, computer graphic, screen display, prints, labels, and packaging:

Date of "creation" (year) - when was the Work completed (i.e., the first day this Work physically embodied in a tangible object). The rights will extend only to the scope of the Work at this date:

Date of first "publication" - first transfer of copies of the Work to the public that is, rental, leasing, lending, or transfer of ownership of copies, or work first shown to the public in non-restricted circumstances (e.g., first presentation of the Work to the public with a view toward sale of the Work or a copy of the Work):

Place of first "publication":

Author's or Authors' Full Name(s):

Author's or Authors' domicile or nationality:

Author's or Authors' date of birth (if available):

Author's or Authors' date of death (if deceased):

Independent contractor or employee:

Name of employer of Author, if any:

If the author(s) were employees at the time of creation, was the work prepared within the scope of his or her employment:
YES/NO------YesNo Comment:

Claimant/Copyright Owner:

Is the Work part of a compilation or derivative work:
YES/NO------YesNo Comment:

Message:

When we have received a signed copy of our engagement letter (automatically sent to you once you click on "Send Information" below), and this filing data, we shall call you to confirm receipt and discuss fees and costs, and any questions we may have.