PART 1
To ________________________________________________________________________________________________________________________ Date _____________________________
(Name of Publisher)
Address ______________________________________________________________________________________________________________________________________________________
Publisher:
We hereby request your permission and non-exclusive license to arrange the following musical composion.
______________________________________________________________________________________________________________________________________________________
By __________________________________________________________________________________________________________________________________________ (words)
____________________________________________________________________________________________________________________________________________ (music)
(hereinaer referred to as “The Arrangement”)
1. The Arrangement will be for ________________________________________________________________________________________________________________
(Type of arrangement)
in ______________________________________________________________________________________________________________________________________
(Number of instrumental and/or vocal parts)
We will produce __________ copies of the Arrangement for use and performance only by our _____________________________________________________________.
(Teachers, students, members etc.)
2. No right to record or to reproduce addional copies is granted to us. We understand that if we wish to record The Arrangement a separate license will be required. We
agree not to distribute (except for use of copies as provided in Paragraph 1), sell, loan or lease copies of The Arrangement to anyone.
PART 2
3. All copies of The Arrangement shall bear the following copyright noce and the words “arranged by permission” at the boom of the rst page of music of
each part of The Arrangement. We will furnish you with a copy of The Arrangement upon compleon.
(Copyright noce)__________________________________________________________________________________________________________________________________________
4. We will have The Arrangement made by a person connected with us as our employee for hire, without any payment obligaon on your part, and on our signature below,
together with yours underneath the words “Permission Granted” below shall assign to you all of our right in The Arrangement and the copyright in The Arrangement together
with the sole right of registering the copyright as a work made for hire in your name or the name of your designee.
5. Addional provisions (if applicable):
6. In consideraon of your permission to arrange, we will pay you $ ________________ upon the granng by you of the permission requested.
7. The license agreement sets forth our enre understanding and may not be modied or amended except by wrien agreement signed by both of us.
Very truly yours,
Name of Instuon ________________________________________________ Address _______________________________________________ By ___________________________________
PERMISSION GRANTED By:_____________________________________________________________________
PERMISSION DENIED BECAUSE:
____ Arrangement available for sale. ____ Arrangement in process of publicaon. ____ May not be arranged because of contractual commitments.
____ Other: _________________________________________________________________________________________________________________________________________________
THIS FORM IS TO BE PREPARED IN DUPLICATE. Aer compleng PART 1 and signing both copies where indicated, forward both to the publisher who will
complete PART 2 of the form and return it to you. If the publisher indicates a payment for the permission you request, and if the condions are agreeable
to you, remit the amount to the publisher together with the original copy, which they will have signed, where-upon the agreement will be completed.
Standard Form Recommended by: Music Publisher’s Associaon of the United States and Naonal Music Publisher’s Associaon, Inc.
Request for Permission to Arrange
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