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 VAS looks like.
FORM VAS
For a Work of the Visual Arts
UNITED STATES COPYRIGHT OFFICE
REGISTRATION NUMBER
___________________________ VA
___________________________ VAU
EFFECTIVE DATE OF REGISTRATION
______________ Month _____________ Day ________ Year
APPLICATION RECEIVED ___________________________
DEPOSIT RECEIVED ONE ___________________________
DEPOSIT RECEIVED TWO ___________________________
FEE RECEIVED ___________________________
EXAMINED BY ___________________________
CORRESPONDENCE ____
DO NOT WRITE ABOVE THIS LINE. IF YOU NEED MORE SPACE, USE A SEPARATE CONTINUATION SHEET.
1 TITLE OF THIS WORK: Alternative title or tile 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: ___________________________
This information must be given in all cases.
4 IF WORK HAS BEEN PUBLISHED, DATA AND NATION OF PUBLICATION
a. Date
Month ___________________________
Day ___________________________
Year ___________________________
b Nation ___________________________
5 TYPE OF AUTHORSHIP IN THIS WORK: Check all that this author created.
____ 3-Dimensional sculpture
____ 2-Dimensional artwork
____ Technical drawing
____ Photographs
____ Jewelry design
____ Map
____ Text
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 ___________________________
OPTIONAL
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 Deposit Account # ___________________________
Name ___________________________