Music In Audio / Visual Carriers (Mechanical License)

REQUEST FORM—

Note:

Fields denoted with an asterisk (*) are mandatory

COMPANY INFO

Company Name *

Company Title

Company Type *

Tax Code *

Tax Office *

ADDRESS INFO

Prefecture *

Municipality - City *

Address *

Zip Code

CONTACT INFO

Phone Number *

Mobile Phone Number

FAX

E-Mail Address *

Web Site / URL

CARRIER INFO

Carrier Type *

Audio Carrier Title *

Carrier Content Duration

Hours *

Minutes *

Seconds *

Barcode

Catalogue Number

MANUFACTURER INFO

Factory

Lab

Other Location

Factory *

Lab *

Manufacturer Description *

Manufacturer Prefecture *

Manufacturer City *

Manufacturer Address *

DISTRIBUTION INFO

Sale

Premium

Free

Other Means

Wholesale Price

Retail Price

Document Title *

Free Distribution Description *

Other Distribution Type Description *

Number Of Copies *

Circulation Date *

Distribution Territory *

EXTRA INFO

Attach cue sheet (files in word, excel, pdf)

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