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For a Work of the Performing Arts (United States)

This is a copyright form for a work of the performing arts. The form provided here is simply a sample of what the actual Form PA looks like.

FORM PA

For a Work of the Performing Arts

UNITED STATES COPYRIGHT OFFICE

REGISTRATION NUMBER ___________________________

____ PA ____ PAU

EFFECTIVE DATE OF REGISTRATION

______________________ Month _____________ Day _______ Year

DO NOT WRITE ABOVE THIS LINE. IF YOU NEED MORE SPACE, USE A SEPARATE CONTINUATION SHEET.

1 TITLE OF THIS WORK ___________________________

PREVIOUS OR ALTERNATIVE TITLES ___________________________

NATURE OF THIS WORK ___________________________

2 NAME OF AUTHOR

NOTE: Under the law, the "author" of a "work made for hire" is generally the employer, not the employee (see instructions). For any part of this work that was "made for hire" check "Yes" in the space provided, give the employer (or other person for whom the work was prepared) as "Author" of that part, and leave the space for dates of birth and death blank.

a ___________________________

DATES OF BIRTH AND DEATH

Year Born ___________________________

Year Died ___________________________

Was this contribution to the work a "work made for hire"? ____ Yes ____ No

AUTHOR'S NATIONALITY OR DOMICILE Name of Country

OR Citizen of ___________________________

Domiciled in ___________________________

WAS THIS AUTHOR'S CONTRIBUTION TO THE WORK

Anonymous? ____ Yes ____ No

Pseudonymous? ____ Yes ____ No

If the answer to either of these questions is "Yes", see detailed instructions.

b ___________________________

DATES OF BIRTH AND DEATH

Year Born ___________________________

Year Died ___________________________

Was this contribution to the work a "work made for hire"? ____ Yes ____ No

AUTHOR'S NATIONALITY OR DOMICILE Name of Country

OR Citizen of ___________________________

Domiciled in ___________________________

WAS THIS AUTHOR'S CONTRIBUTION TO THE WORK

Anonymous? ____ Yes ____ No

Pseudonymous? ____ Yes ____ No

If the answer to either of these questions is "Yes", see detailed instructions.

c ___________________________

DATES OF BIRTH AND DEATH

Year Born ___________________________

Year Died ___________________________

Was this contribution to the work a "work made for hire"? ____ Yes ____ No

AUTHOR'S NATIONALITY OR DOMICILE Name of Country

OR Citizen of ___________________________

Domiciled in ___________________________

WAS THIS AUTHOR'S CONTRIBUTION TO THE WORK

Anonymous? ____ Yes ____ No

Pseudonymous? ____ Yes ____ No

If the answer to either of these questions is "Yes", see detailed instructions.

3 a YEAR IN WHICH CREATION OF THIS WORK WAS COMPLETED

Year ___________________________

This information must be given in all cases.

b DATE AND NATION OF FIRST PUBLICATION OF THIS PARTICULAR WORK

Complete this information ONLY if this work has been published.

___________________ Month ________________ Day ____________ Year

Nationality ___________________________

4 See instructions before completing this space.

COPYRIGHT CLAIMANT(S) Name and address must be given even if the claimant is the same as the author given in space 2.

___________________________

TRANSFER: If the claimant(s) named here in space 4 is (are) different from the author(s) named in space 2, give a brief statement of how the claimant(s) obtained ownership of the copyright.

___________________________

DO NOT WRITE HERE, OFFICIAL USE ONLY

APPLICATION RECEIVED ___________________________

ONE DEPOSIT RECEIVED ___________________________

TWO DEPOSITS RECEIVED ___________________________

FUNDS RECEIVED ___________________________

___________________________

EXAMINED BY ___________________________

CHECKED BY ___________________________

CORRESPONDENCE ____ Yes

___________________________

DO NOT WRITE ABOVE THIS LINE. IF YOU NEED MORE SPACE, USE A SEPARATE CONTINUATION SHEET.

5 PREVIOUS REGISTRATION Has registration for this work, or for an earlier version of this work, already been made in the Copyright Office?

____ Yes ____ No If your answer is "Yes," why is another registration being sought? (Check appropriate box.) If your answer is "no," go to space 7.

a. _____ This is the first published edition of a work previously registered in unpublished form.

b. ____ This is the first application submitted by this author as copyright claimant.

c. ____ This is a changed version of the work, as shown by space 6 on this application.

If your answer is "Yes," give Previous Registration Number

___________________________

Year of Registration ___________________________

6a DERIVATIVE WORK OR COMPILATION Complete both space 6a and 6b for a derivative work: complete only 6b for a compilation. Preexisting Material Identify any preexisting work or works that this work is based on or incorporates.

___________________________

6b Material Added to This Work. Give a brief, general statement of the material that has been added to this work and in which copyright is claimed.

___________________________

7a DEPOSIT ACCOUNT If the registration fee is to be charged to a Deposit Account established in the Copyright Office, give name and number of Account.

Name ___________________________

Account Number ___________________________

7b CORRESPONDENCE Give name and address to which correspondence about this application should be sent.

Name ___________________________

Address ___________________________

Apt ___________________________

City ___________________________

State ___________________________

ZIP ___________________________

Area code and daytime telephone number ___________________________

Fax Number ___________________________

Email ___________________________

8 CERTIFICATION* I, the undersigned, hereby certify that I am the (check only one)

____ author

____ other copyright claimant

____ owner of exclusive right(s)

____ authorized agent of ___________________________ Name of author or other copyright claimant, or owner of exclusive right(s)

of the work identified in this application and that the statements made by me in this application are correct to the best of my knowledge.

Typed or printed name and date. If this application gives a date of publication in space 3, do not sign and submit it before that date.

Handwritten signature (X) ___________________________

Date ___________________________

9 Name ___________________________

Number/Street/Apt ___________________________

City/State/ZIP ___________________________

YOU MUST:
• Complete all necessary spaces
• Sign your application in space 8

SEND ALL ELEMENTS IN THE SAME PACKAGE:
1. Application form
2. Nonrefundable filing fee in check or money order payable to Register of Copyrights
3. Deposit material

MAIL TO

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


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