For a Work of the Visual Arts (United States)
This is a copyright form for a work of the Visual Arts. The form provided here is simply a sample of what the actual Form VAI looks like.
FORM VAI
For a Work of the Visual Arts
UNITED STATES COPYRIGHT OFFICE
REGISTRATION NUMBER
___________________________ VA
___________________________ VAU
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 ___________________________
NATURE OF THIS WORK ___________________________
PREVIOUS OR ALTERNATIVE TITLES ___________________________
Publication as a Contribution If this work was published as a contribution to a periodical, serial, or collection, give information about the collective work in which the contribution appeared.
Title of Collective Work ___________________________
If published in a periodical or serial give:
Volume ___________________________
Number ___________________________
Issue Date ___________________________
On Pages ___________________________
2a NAME OF AUTHOR ___________________________
Was this contribution to the work a "word made for hire"?
____ Yes ____ No
AUTHOR'S NATIONALITY OR DOMICILE
Citizen of ___________________________
OR
Domiciled in ___________________________
DATE OF BIRTH AND DEATH
Year Born ___________________________
Year Died ___________________________
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.
NATURE OF AUTHORSHIP Check appropriate box(es).
____ 3-Dimensional sculpture
____ 2-Dimensional artwork
____ Reproduction of work of art
____ Map
____ Photograph
____ Jewelry design
____ Technical drawing
____ Text
____ Architectural work
2a NAME OF AUTHOR ___________________________
Was this contribution to the work a "word made for hire"?
____ Yes ____ No
AUTHOR'S NATIONALITY OR DOMICILE
Citizen of ___________________________
OR
Domiciled in ___________________________
DATE OF BIRTH AND DEATH
Year Born ___________________________
Year Died ___________________________
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.
NATURE OF AUTHORSHIP Check appropriate box(es).
____ 3-Dimensional sculpture
____ 2-Dimensional artwork
____ Reproduction of work of art
____ Map
____ Photograph
____ Jewelry design
____ Technical drawing
____ Text
____ Architectural work
3a Year in Which Creation of This Work Was Completed
___________________________ Year
This information must be given in all cases.
3b DATA AND NATION OF FIRST PUBLICATION OF THIS PARTICULAR ISSUE
Complete this information ONLY if this work has been published.
Month ___________________________
Day ___________________________
Year ___________________________
___________________________ Nation
4 See instructions before completing this space.
a COPYRIGHT CLAIMANT(S) Name and address must be given even if the claimant is the same as the author given in space 2.
___________________________
b 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 ___________________________
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