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For a Serial Group (United States)

This is a copyright form for a Serial Group. The form provided here is simply a sample of what the actual Form SE/GROUP looks like.

FORM SE
For Serial Group

UNITED STATES COPYRIGHT OFFICE

REGISTRATION NUMBER ___________________________

EFFECTIVE DATE OF REGISTRATION ___________________________

APPLICATION RECEIVED ___________________________

ONE DEPOSIT RECEIVED ___________________________

EXAMINED BY ___________________________

CORRESPONDENCE _____

DO NOT WRITE ABOVE THIS LINE.


1 List in order of publication

No previous registration under identical title ____

TITLE ___________________________

ISSN ___________________________

1. Volume ___________________________

Number ___________________________

Issue date on copies ___________________________

Month, day, and year of publication ___________________________

2. Volume ___________________________

Number ___________________________

Issue date on copies ___________________________

Month, day, and year of publication ___________________________

3. Volume ___________________________

Number ___________________________

Issue date on copies ___________________________

Month, day, and year of publication ___________________________

4. Volume ___________________________

Number ___________________________

Issue date on copies ___________________________

Month, day, and year of publication ___________________________

2a NAME AND ADDRESS OF THE AUTHOR/COPYRIGHT CLAIMANT IN THESE COLLECTIVE WORKS MADE FOR HIRE ___________________________

FOR NON-U.S. WORKS: Author's citizenship ___________________________

Domicile ___________________________

Nation of publication ___________________________

CERTIFICATION*: I, the undersigned, hereby certify that I am the copyright claimant or the authorized agent of the copyright claimant of the work identified in this application, that all the conditions specified in the instructions on the back of this form are met, that I have deposited two complimentary subscription copies with the Library of Congress, and that the statements made by me in this application are correct to the best of my knowledge.

Handwritten signature (X) ___________________________

Type or printed name ___________________________

PERSON TO CONTACT FOR CORRESPONDENCE ABOUT THIS CLAIM

Name ___________________________

Daytime telephone ___________________________

Address (if other than give below) ___________________________

Fax ___________________________

Email ___________________________

Certificate will be mailed in window envelope to this address:

Name ___________________________

Number/Street/Apt ___________________________

City/State/ZIP ___________________________

DEPOSIT ACCOUNT

Account Number ___________________________

Name of Account ___________________________

MAIL TO

Library of Congress
Copyright Office
101 Independence Avenue, S.E.
Washington, D.C. 20559-6000


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