APPLICATION FOR COPYRIGHT (Please read instructions carefully before filling blanks).

Date __________, 200____ The DIRECTOR, The National Library, Manila Sir: I have the honor to apply for the copyright registration of the
(A) UNPUBLISHED (B) PUBLISHED

(work named herein of which ) (work named herein of which)

(C) ______________ COMPLETE COPIES (D) PHOTOGRAPHS (E) A TITLE AND DESCRIPTION WITH THE REQUIRED PRINTS

is or are herewith deposited accompanied by the required affidavit in compliance with the provisions of Presidential Decree No. 49. The amount of P8.30 for the registration, publication and certificate fees and thirty centavos for the stamp to be affixed to the certificate are also enclosed. The data required by the rules and regulations of that office follow: 1. Name and address of copyright owner: ______________________________
(GIVE CLAIMANTS FULL LEGAL NAME,

______________________________________________________________
& WRITE HIS STREET NUMBER, MUNICIPALITY & PROVINCE VERY CLEARLY & LEGIBLY)

2. Name of the author: _____________________________________________ 3. Country of which the author is a citizen ______________________________;
(NAME OF COUNTRY MUST BE STATED)

4. If alien author, state Alien Certificate No. and where ciled in the Philippines: ______________________________________________________________ 5. Title of the work: ________________________________________________
(GIVE THE TITLE EXACTLY AS IT APPEARS ON THE FRONT PART

______________________________________________________________
OR TITLE (PAGE OF THE WORK FOLLOWED BY THE EDITION NUMBER, IF ANY)

6. Class to which the work belongs: ___________________________________ 7. If copyright is claimed upon new matter in a reissued work, state new matter specifically:
(MENTION ADDITIONAL CHAPTERS BY NUMBERS FOLLOWED BY INCLUSIVE PAGES IN PARENTHESIS OTHER MORE OR LESS SHORT BUT MATERIAL ALTERATIONS AND ADDITIONS MAY BE INDICATED BY MENTION OF PARAGRAPH OR PAGES)

____________________ and give registry number of next previous edition copyrighted;

8. (F) MADE, PRODUCED OR PERFORMED (G) PRINTED OR REPRODUCED IN COPIES

on the _________ day of _________,

(DATE WHEN THE WORK OR ITS PRINTING WAS COMPLETED)

200__ at ___________________ by _________________________________________

(MUNICIPALITY/PROVINCE) (NAME OF PERSON/ ESTABLISHMENT MAKING THE PRINTING/ REPRODUCTION IN COPIES)

9. First published or sold to the public in the Philippines on the ______________________________________________________________

(STATE DAY THE WORK WAS PLACED ON SALE, SOLD, OR PUBLICLY DISTRIBUTED)

day of ________________________, 200___, at _________________________

(MUNICIPALITY/PROVINCE)

by ______________________________________________________________
(NAME OF PERSON AND ESTABLISHMENT)

10. Send certificate of registration to: __________________________________

(WRITE THE NAME AND ADDRESSLEGIBLY)

11. Unit price if reproduced in copies for sale: P _____________________ Very respectfully, _______________________ _ (Signature of Applicant) AFFIDAVIT (IMPORTANT This affidavit must be executed by individual an official of a corporation or firm may act and must be under the seal of an officer authorized to administer oaths within the Philippines. In case of published works, the execution must be subsequent to the date of publication. The affiant must fill in the required statements to accord with the facts concerning the work named, and draw pen through statements not intended to be made.) REPUBLIC OF THE PHILIPPINES ) PROVINCE OF _______________ ) SS MUNICIPALITY OF ___________ ) I, _____________, {BEING DULY SWORN, DEPOSE DO SOLEMLY AFFIRM} and say:
(A) PERSON CLAIMING COPYRIGHT IN (B) PRINTER WHO PRINTED

That I am the

(C) DULY AUTHORIZED AGENT OR REPRESENTATIVE RESIDING IN THE PHILIPPINES OF THE CLAIMANT OF COPYRIGHT IN

the work named therein;

(D) I AM ACTUALLY A RESIDENT OF THE MUNICIPALITY OF ________________, PROVINCE OF _______________, AND

that

(E) ____________________________________________ OF _________________________ (NAME OF CLAIMANT IF OTHER THAN AFFIANT) (MUNICIPALITY, PROVINCE)

claim ownership of (F) AS copyright in the (G) BY ASSIGNMENT FROM said work (H) BY INHERITANCE FROM
(I) COMPLETE COPIES (J) PHOTOGRAPHS (K) A TITLE AND DESCRIPTION WITH THE REQUIRED PRINTS

the author thereof; that the

said work of which

have been deposited, is entitled ______________________________________________________________________

(GIVE THE TITLE EXACTLY AS IT APPEARS ON THE FRONT PART OR TITLE PAGE OF THE WORK. FOLLOW IT BY EDITION NUMBER IF ANY, THEN BY AUTHORS NAME IF HE IS DIFFERENT FROM CLAIMANT)

and has been printed

(L) MADE, PRODUCED OR PERFORMED (M) PRINTED OR REPRODUCED IN COPIES

at ______________________
(MUNICIPALITY,PROVINCE)

by _______________________________; the work or its printing or reproduction having

(NAME OF PERSON OR ESTABLISHMENT)

been completed on the _____________ day of _______________, 200__; and that the said work was first published or sold to the public in the Philippines on the _______________________________________________ day of __________, 200__ at
(MUST AGREE WITH THE DATE GIVEN IN THE APPLICATION)

__________________________ ___________________________________________
(MUNICIPALITY, PROVINCE) (NAME OF PERSON OR ESTABLISHMENT)

by

__________________________________________

(Signature of person making affidavit) Subscribed and sworn to or affirmed before me this _________ day of ______________, 200__. The deponent in the foregoing affidavit exhibited to me his Residence Certificate No. _____________ issued at the Municipality of ____________, Province of ________________ Philippines, on _______________, 200___. TIN NO. ___________________________ ___________________________________ NOTARY PUBLIC

My commission expires on Dec. 31, 200__ Doc. No. ___________; Page No. ___________; Book No. ___________; Series of 200__.