Fields with a red asterisk (*) must be filled out to complete the form

Company Name:*     Purchase Order #:
Client Code:     Phone:     Email:*

Production Title:*
Client or End User's Name:*
Date of First Use:   ISCI Code (National Spot):
First Line of Copy (Commercials only):

Clearance Codes (please choose the appropriate button):*

Non-Broadcast
101 Non-Broadcast video, film, DVD/CD-ROM or audio production not for retail sale
102 Non-Broadcast video, film, DVD/CD-ROM, Internet or audio production offered for retail sale
105 Internet Production
Broadcast
201 Local TV, Radio or Cable Production not for retail sale
202 Local TV, Radio or Cable Production offered for retail sale
203 Regional TV, Radio or Cable Production not for retail sale
204 Regional TV, Radio or Cable Production offered for retail sale
205 National TV, Radio or Cable Production not for retail sale
206 National TV, Radio or Cable Production offered for retail sale
207 Local TV or Radio Commercial
208 Regional TV or Radio Commercial
209 National TV or Radio Commercial
210 Broadcast Promo
211 Public Service Announcement (Radio or TV)
Other
301 Theme Use - Broadcast (use in unlimited productions for one year)
302 Theme Use - Non-Broadcast (use in unlimited productions for one year)
303 Theme Use - Educational (use in unlimited productions for one year)
304 Music-On-Hold
305 Live Performance
306 Theatrical, no duplication or retail sale*
307 Theatrical, with duplication, no retail sale*
308 Theatrical, with duplication and retail sale*
309 Theatrical trailer*
310 Foreground Music*
401 Video Game Soundtrack, single platform
402 Video Game Soundtrack, multiple platforms
601 All TV Media, worldwide in perpetuity, unlimited dup and retail sale*

* not covered by blanket agreements

Retail Sale: Will more than 100 units of this production be made for retail sale?  Yes No *
If yes, how many?
101 to 1,000 1,001 to 10,000 10,001 to 50,000
50,001 to 100,000 100,001 or more

Duplication: Will more than 1,000 copies of this production be made?  Yes No *

Will a Performing Rights license be required for this production?  Yes No *

 Music Selections Used

CD#
Track#
Song Title
# of Drops
Client Type:*   Annual Blanket   Annual Drop-On-Loan   Drop Client. Please bill me.
Please complete this area if license or invoice is to be issued to a third party

Issue License to:

Name: 
Company: 
Street: 
City:  State:  Zip: 

Send Invoice to:

Name: 
Company: 
Street: 
City:  State:  Zip: 

Conditions of license: (1) This license permits the synchronization and mechanical reproduction of our music for use as background music in this production only. Alteration of the production may require an additional license. (2) Duplication of the production containing this music is limited to the number of copies specified on the face of this license. (3) This license is not valid for the use of our music in adult-entertainment productions, in any production where the music constitutes the primary value of the production, or where the music is offered as a separate and distinct element for reuse by others. (4) Unless specifically granted, this license does not convey any rights of public performance. (5) Omni's liability for this license shall not exceed the consideration paid. (6) All rights not herein granted are reserved by Omni. This license is issued in the State of New York and shall be subject to interpretation only under the laws of the State.