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