Copyright Questionnaire - Widerman Malek, PL

Name*

First Last

Address*

Street Address State / Province / Region ZIP / Postal Code

Phone*

Type of business entity

What type of work is this?

Work of the performing arts (musical and dramatic works, pantomimes and choreographic works, motion pictures, and other audiovisual works, including computer program screen outputs)?
Sound recording?
Work of the visual arts (paintings, sketchings, drawings, sculptures, maps, photographs, scale models, jewelry designs, fabric designs, architectural design)?
Nondramatic literary work (fiction, non-fiction, poetry, textbooks, reference works, directories, catalogs, advertising copy, compilations of information, computer program)?

Year the work was created

(Work of the performing arts)

If this work is a contribution to a periodical or collection of various works, please give the title of this individual contribution and the title of the collection as a whole.

Describe the general character of this work (i.e., instructional video tape, musical recording, lithographic print).

Have copies of this work been publicly distributed or given to another for purposes of distribution to the public? If so, please describe the circumstances, and give the date.

Yes
No

Date

What is the exact title of this work?

What is the full legal name of the person who actually created this work (the author)?

What is the date of birth of the person who actually created this work (the author)?

What is the nation of citizenship of the person who actually created this work (the author)?

Was this work done anonymously or pseudonymously?

Yes
No

Was the work prepared by an employee acting within the scope of his/her employment or under a written agreement with the person who prepared the work?

Yes
No

If there is more than one author, what was each author’s contribution to this work (i.e., text, photography, artwork, illustrations)?

Who owns the copyright in the work? If different from the author of the work, please explain how ownership was obtained (i.e., copyright was assigned, author is the employee of the copyright owner).

Applicant owns copyright as author is full-time employee and work was within scope of duties.
Application owns copyright as author signed written agreement assigning rights to work.
Other circumstance

If other circumstance, type here

Has this work, or an earlier version of this work, been previously registered with the Copyright Office? If so, what is the Registration No. and date of registration? Why is another registration being sought?

Yes
No

If yes: Registration No.

If yes, Date:

If yes, new registration sought because:

Is this work derived, or based on, a pre-existing work? (i.e., a translation or abridgment)? If so, how does this work differ from the pre-existing work (i.e., sculpture based on a drawing)?

Yes
No

If yes: difference

Does this work consist of a collection of pre-existing materials or information which you have selected from a number of sources? If so, please describe this collection (i.e., compilation of 19th century political cartoons).

Yes
No

If yes: collection comprises

When was this work completed?

Email

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