Sample Clearance Form

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Sample Clearance Form

SAMPLE CLEARANCE REQUEST FORM

(Please fill out this form to the best of your ability. You will be able to save and review your submission before sending to us.)

SECTION 1: NEW WORK - BASIC INFORMATION

ARTIST or GROUP NAME:

Enter the name of the Artist or Group featured on the New Work.

SONG TITLE:

Enter the title of the New Work that contains the sample to be cleared.

SONG LENGTH:

How long is the running time of the New Work?

LICENSEE NAME:

What is the name of the record label or company releasing the New Work?

AUDIO LINK for the NEW WORK:

Please enter link to the New Work:

SECTION 2: NEW WORK - WRITER/PUBLISHER SPLITS

WRITER #1 NAME:

Enter the legal name of Writer #1 the way it is listed at the PRO.

WRITER #1 % SHARE:

Use whole numbers (ex. 50 to show 50% publishing claim).

WRITER #1 IPI #:

Enter the IPI of the writer (not the member number).

WRITER #1 PRO:

WRITER #1 CONTRIBUTION:

Author

Composer

Both

OTHER PRO NAME #1:

PUBLISHER #1 NAME:

PUBLISHER #1 IPI #:

WRITER #1 PHONE #:

WRITER #1 EMAIL:

ADD 2ND WRITER?

Yes

NEW WORK - WRITER #2

WRITER #2:

Enter the legal name of Writer #2.

WRITER #2 % SHARE:

Use whole numbers (ex. 50 to show 50% publishing claim).

WRITER #2 IPI #:

Enter the IPI of the writer (not the member number).

WRITER #2 PRO:

WRITER #2 CONTRIBUTION:

Author

Composer

Both

OTHER PRO NAME #2:

PUBLISHER #2 NAME:

PUBLISHER #2 IPI #:

WRITER #2 PHONE:

WRITER #2 EMAIL:

ADD 3RD WRITER?

Yes

NEW WORK - WRITER #3

WRITER #3:

Enter the legal name of Writer #3.

WRITER #3 % SHARE:

Use whole numbers (ex. 50 to show 50% publishing claim).

WRITER #3 IPI #:

Enter the IPI of the writer (not the member number).

WRITER #3 PRO:

WRITER #3 CONTRIBUTION:

Author

Composer

Both

OTHER PRO NAME #3:

PUBLISHER #3 NAME:

PUBLISHER #3 IPI#:

WRITER #3 PHONE:

WRITER #3 EMAIL:

ADD 4TH WRITER?

Yes

NEW WORK - WRITER #4

WRITER #4:

Enter the legal name of Writer #4.

WRITER #4 % SHARE:

Use whole numbers (ex. 50 to show 50% publishing claim).

WRITER #4 IPI #:

Enter the IPI of the writer (not the member number).

WRITER #4 PRO:

WRITER #4 CONTRIBUTION:

Author

Composer

Both

OTHER PRO NAME #4:

PUBLISHER #4 NAME:

PUBLISHER #4 IPI #:

WRITER #4 PHONE #:

WRITER #4 EMAIL:

ADD 5TH WRITER?

Yes

NEW WORK - WRITER #5

WRITER #5:

Enter the legal name of Writer #5.

WRITER #5 % SHARE:

Use whole numbers (ex. 50 to show 50% publishing claim).

WRITER #5 IPI #:

Enter the IPI of the writer (not the member number).

WRITER #5 PRO:

WRITER #5 CONTRIBUTION:

Author

Composer

Both

OTHER PRO NAME #5:

PUBLISHER #5 NAME:

PUBLISHER #5 IPI #:

WRITER #5 PHONE #:

WRITER #5 EMAIL:

ADD 6TH WRITER?

Yes

NEW WORK - WRITER #6

WRITER #6:

Enter the legal name of Writer #6.

WRITER #6 % SHARE:

Use whole numbers (ex. 50 to show 50% publishing claim).

WRITER #6 IPI #:

Enter the IPI of the writer (not the member number).

WRITER #6 PRO:

WRITER #6 CONTRIBUTION:

Author

Composer

Both

OTHER PRO NAME #6:

PUBLISHER #6 NAME:

PUBLISHER #6 IPI #:

WRITER #6 PHONE #:

WRITER #6 EMAIL:

ADD 7TH WRITER?

Yes

NEW WORK - WRITER #7

WRITER #7:

Enter the legal name of Writer #7.

WRITER #7 % SHARE:

Use whole numbers (ex. 50 to show 50% publishing claim).

WRITER #7 IPI #:

Enter the IPI of the writer (not the member number).

WRITER #7 PRO:

WRITER #7 CONTRIBUTION:

Author

Composer

Both

OTHER PRO NAME #7:

PUBLISHER #7 NAME:

PUBLISHER #7 IPI #:

WRITER #7 PHONE #:

WRITER #7 EMAIL:

ADD 8TH WRITER?

Yes

NEW WORK - WRITER #8

WRITER #8:

Enter the legal name of Writer #8.

WRITER #8 % SHARE:

Use whole numbers (ex. 50 to show 50% publishing claim).

WRITER #8 IPI #:

Enter the IPI of the writer (not the member number).

WRITER #8 PRO:

WRITER #8 CONTRIBUTION:

Author

Composer

Both

PUBLISHER #8 NAME:

PUBLISHER #8 IPI #:

OTHER PRO NAME #8:

WRITER #8 PHONE #:

WRITER #8 EMAIL:

SECTION 3: ORIGINAL WORK(S) INFORMATION

ORIGINAL ARTIST or GROUP NAME #1:

Enter the name of the artist or group that was sampled or interpolated.

ORIGINAL WORK TITLE #1:

Enter the name of the original work that was sampled or interpolated.

ORIGINAL ALBUM TITLE #1:

Enter the title of the album/ep/single that contains the original work that was sampled or interpolated. You can leave blank if there is no name.

LENGTH OF USE #1:

How many bars, seconds, or minutes of the original work is being used in the new work?

PORTION OF ORIGINAL WORK #1 USED:

Examples: Intro, Chorus, Drums, Vocals, Lyrics, Piano Loop, etc.

WHERE #1 USED (IN NEW WORK)?:

Where does the sample or interpolation of the original work happen in the new work? (ex. used throughout, used in the hook, used in verse 2, etc.)

LINK TO ORIGINAL WORK #1:

Let us hear what inspired you.

ADD 2ND SAMPLE?

Yes

ADDITIONAL ORIGINAL WORK INFORMATION #2

ORIGINAL ARTIST or GROUP NAME #2:

Enter the name of the artist or group that was sampled or interpolated.

ORIGINAL WORK #2 TITLE:

Enter the name of the original work that was sampled or interpolated.

ORIGINAL ALBUM TITLE #2:

Enter the title of the album/ep/single that contains the original work that was sampled or interpolated. You can leave blank if there is no name.

LENGTH OF USE #2:

How many bars, seconds, or minutes of the original work is being used in the new work?

PORTION OF ORIGINAL WORK #2 USED:

Examples: Intro, Chorus, Drums, Vocals, Lyrics, Piano Loop, etc.

WHERE #2 USED (IN NEW WORK)?:

Where does the sample or interpolation of the original work happen in the new work? (ex. used throughout, used in the hook, used in verse 2, etc.)

LINK TO ORIGINAL WORK #2:

Let us hear what inspired you.

ADD 3RD SAMPLE?

Yes

ADDITIONAL ORIGINAL WORK INFORMATION #3

ORIGINAL ARTIST or GROUP NAME #3:

ORIGINAL WORK #3 TITLE:

Enter the name of the original work that was sampled or interpolated.

ORIGINAL ALBUM TITLE #3:

Enter the title of the album/ep/single that contains the original work that was sampled or interpolated. You can leave blank if there is no name.

LENGTH OF USE #3:

How many bars, seconds, or minutes of the original work is being used in the new work?

PORTION OF ORIGINAL WORK #3 USED:

Examples: Intro, Chorus, Drums, Vocals, Lyrics, Piano Loop, etc.

WHERE #3 USED (IN NEW WORK)?:

Where does the sample or interpolation of the original work happen in the new work? (ex. used throughout, used in the hook, used in verse 2, etc.)

LINK TO ORIGINAL WORK #3:

Let us hear what inspired you.

ADD 4TH SAMPLE?

Yes

ADDITIONAL ORIGINAL WORK INFORMATION #4

ORIGINAL ARTIST or GROUP NAME #4:

Enter the name of the artist or group that was sampled or interpolated.

ORIGINAL WORK TITLE #4:

Enter the name of the original work that was sampled or interpolated.

ORIGINAL ALBUM TITLE #4:

Enter the title of the album/ep/single that contains the original work that was sampled or interpolated. You can leave blank if there is no name.

LENGTH OF USE #4:

How many bars, seconds, or minutes of the original work is being used in the new work?

PORTION OF ORIGINAL WORK #4 USED:

Examples: Intro, Chorus, Drums, Vocals, Lyrics, Piano Loop, etc.

WHERE #4 USED (IN NEW WORK)?:

Where does the sample or interpolation of the original work happen in the new work? (ex. used throughout, used in the hook, used in verse 2, etc.)

LINK TO ORIGINAL WORK #4:

Let us hear what inspired you.

ADD 5TH SAMPLE?

Yes

ADDITIONAL ORIGINAL WORK INFORMATION #5

ORIGINAL ARTIST or GROUP NAME #5:

Enter the name of the artist or group that was sampled or interpolated.

ORIGINAL WORK TITLE #5:

Enter the name of the original work that was sampled or interpolated.

ORIGINAL ALBUM TITLE #5:

Enter the title of the album/ep/single that contains the original work that was sampled or interpolated. You can leave blank if there is no name.

LENGTH OF USE #5:

How many bars, seconds, or minutes of the original work is being used in the new work?

PORTION OF ORIGINAL WORK #5 USED:

Examples: Intro, Chorus, Drums, Vocals, Lyrics, Piano Loop, etc.

WHERE #5 USED (IN NEW WORK)?:

Where does the sample or interpolation of the original work happen in the new work? (ex. used throughout, used in the hook, used in verse 2, etc.)

LINK TO ORIGINAL WORK #5:

Let us hear what inspired you.

ADD 6TH SAMPLE?

Yes

ADDITIONAL ORIGINAL WORK INFORMATION #6

ORIGINAL ARTIST or GROUP NAME #6:

Enter the name of the artist or group that was sampled or interpolated.

ORIGINAL WORK TITLE #6:

Enter the name of the original work that was sampled or interpolated.

ORIGINAL ALBUM TITLE #6:

Enter the title of the album/ep/single that contains the original work that was sampled or interpolated. You can leave blank if there is no name.

LENGTH OF USE #6:

How many bars, seconds, or minutes of the original work is being used in the new work?

PORTION OF ORIGINAL WORK #6 USED:

Examples: Intro, Chorus, Drums, Vocals, Lyrics, Piano Loop, etc.

WHERE #6 USED (IN NEW WORK)?:

Where does the sample or interpolation of the original work happen in the new work? (ex. used throughout, used in the hook, used in verse 2, etc.)

LINK TO ORIGINAL WORK #6:

Let us hear what inspired you.

ADD 7TH SAMPLE?

Yes

ADDITIONAL ORIGINAL WORK INFORMATION #7

ORIGINAL ARTIST or GROUP NAME #7:

Enter the name of the artist or group that was sampled or interpolated.

ORIGINAL WORK TITLE #7:

Enter the name of the original work that was sampled or interpolated.

ORIGINAL ALBUM TITLE #7:

Enter the title of the album/ep/single that contains the original work that was sampled or interpolated. You can leave blank if there is no name.

LENGTH OF #7 USE:

How many bars, seconds, or minutes of the original work is being used in the new work?

PORTION OF ORIGINAL WORK #7 USED:

Examples: Intro, Chorus, Drums, Vocals, Lyrics, Piano Loop, etc.

WHERE #7 USED (IN NEW WORK)?:

Where does the sample or interpolation of the original work happen in the new work? (ex. used throughout, used in the hook, used in verse 2, etc.)

LINK TO ORIGINAL WORK #7:

Let us hear what inspired you.

SECTION 4: NEW CLIENT INFORMATION

LICENSEE NAME:

Name of the company or individual receiving the license(s).

CONTACT NAME:

Name of the contact person if different than the name above.

ADDRESS:

Street Address City State / Province / Region ZIP / Postal Code Country

EMAIL:

PHONE:

DISTRIBUTOR:

OTHER DISTRIBUTOR NAME:

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