For a Work of the Performing Arts - Short Form (United States)
This is a copyright short form for a work of the performing arts. The form provided here is simply a sample of what the actual Short Form PA looks like.
SHORT FORM PA
For a Work of the Performing Arts
UNITED STATES COPYRIGHT OFFICE
REGISTRATION NUMBER ___________________________
____ PA ____ PAU
EFFECTIVE DATE OF REGISTRATION
_____________________ Month ________________ Day _____________ Year
APPLICATION RECEIVED ___________________________
ONE DEPOSIT RECEIVED ___________________________
TWO DEPOSITS RECEIVED ___________________________
FEE RECEIVED ___________________________
EXAMINED BY ___________________________
CHECKED BY ___________________________
CORRESPONDENCE ____ Yes
___________________________
DO NOT WRITE ABOVE THIS LINE. IF YOU NEED MORE SPACE, USE A SEPARATE CONTINUATION SHEET.
1 Title of This Work ___________________________
Alternative title or title of larger work in which this work was published:
___________________________
2 Name and Address of Author and Owner of the Copyright:
Nationality or domicile:
___________________________
___________________________
Phone ___________________________
Fax ___________________________
Email ___________________________
3 Year of Creation: ___________________________
4 If work has been published, Date and Nation of Publication:
a. Date _________________ Month ______________ Day _________ Year
b. Nation ___________________________
5 Type of Authorship in This Work: Check all that this author created.
____ Music
____ Lyrics
____ Other text (includes dramas, screenplays, etc.) (If your work is a motion picture or other audiovisual work, use the Standard Form PA.)
6 Signature: (Registration cannot be completed without a signature)
I certify that the statements made by me in this application are correct to the best of my knowledge* Check one:
____ Author
____ Authorized agent
X ___________________________
7 Name and Address of Person to Contact for Rights and Permissions:
____ Check here if same as #2 above
___________________________
Phone ___________________________
Fax ___________________________
Email ___________________________
8 Certificate will be mailed in window envelope to this address:
Name ___________________________
Number/Street/Apt ___________________________
City/State/ZIP ___________________________
9 Complete this space only if you currently hold a Deposit Account in the Copyright Office:
Deposit Account # ___________________________
Name ___________________________