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Name and Address of the Licensee

Publisher/licensee

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Street and house number

Postal code

City

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Phone

Information About the Used Work

Title, composer, publisher

Edition title, publisher number

Page number (quote, measures etc.)

Use of engravings

Yes

Purpose of Use

Title of publication

Type of publication (songbook, collection, magazine, program, dissertation, CD booklet etc.)

Published by publisher

Publisher address

Distribution area

Publication date

Retail price

Print run

Total number of pages

Number of works

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Name and Address of the Licensee

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Purpose of Use

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