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    Licensing Request Form

    Contact Info
    Company Name:
    City: State: Zip:
    Song Selection
    Which song(s) would you like to license? (Unsure? Describe the mood and we'll make suggestions.)
    Project Description
    Please provide a brief description of how the music will be used:
    1. Will you be duplicating the final product?   Yes No
        1a. If so, how many copies will be duplicated?
    2. Will the final product be available for sale?   Yes No
        2a. If 'yes', please specify the product's retail cost:
    3. Please specify your market distribution:     Regional     National     World
    Your Organization
    Have you ever done business with The O'Neill Brothers or the Harry Fox Agency? Yes No
    Which category best describes your organization?
    Please state your organization's approximate annual gross receipts: