Fillable Securetest-declaration Declaration for Secure Tests and Test Items Prepared for Use in a Secure Test

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Securetest-declaration Declaration for Secure Tests and Test Items Prepared for Use in a Secure Test

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UNITED STATES COPYRIGHT OFFICE
5
Declaration for Secure Tests and Test Items
Prepared for Use in a Secure Test
The undersigned, as the applicant or the applicant’s duly authorized agent or representative, hereby declares under
penalty of perjury under the laws of the United States of America that the redacted copy of the work(s) entitled
presented to the United States Copyright Oce during the
examination appointment is a true and exact copy of the redacted copy of the work(s) uploaded to the Oce’s
electronic registration system on ,
claim number .
Note: Any person who knowingly makes a false representation of a material fact in the application for copyright registration
provided for by section 409, or in any written statement led in connection with the application, is subject to criminal penalties.
See 18 U.S.C. § 506(e); 18 U.S.C. § 1001.
U. S. Copyright Oce · Library of Congress · 101 Independence Avenue SE · Washington, DC 20559 · www.copyright.gov
11 ⁄ 2017
TITLE OF WORK(S)
DATE OF EXAMINATION APPOINTMENT
DATE OF ONLINE SUBMISSION
CLAIM NUMBER
SIGNATURE
NAME (PLEASE PRINT LEGIBLY) DATE
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Securetest-declaration Declaration for Secure Tests and Test Items Prepared for Use in a Secure Test

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Completed 10 July 2020

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