FIFTH LEVEL MUSIC GROUP
COMMERCIAL SYNCHRONIZATION
LICENSE REQUEST FORM
Date:_________________________________________
Advertising Agency: __________________________________________
Contact Name: ______________________________________________
Address: ___________________________________________________
___________________________________________________________
Phone Number: (___) _____ - ____________
Fax Number: (___) _____ - _______________
Email: ___________________________________________
Licensee Name: ___________________________________
Product: _________________________________________
SONG TITLE: ________________________________________________
Writers: ____________________________________________________
Master Recording or Re-Recording?______________________________________
If Master, please list original artist: ____________________________________________
Use: Background ________ Visual __________
Format: Vocal _____________ Instrumental _____
Timing of Song: ___________
Length of Spot: ___________
Media (TV, radio, cable, etc) List all that apply:
_________________________________________________________
_________________________________________________________
Territory: _______________________________________
Term: __________________________________________
Start Date: ______________________________________
Number of spots/lifts: _____________________________
Script / Storyboard available? Yes ____ No ____
If yes, please attach and send the synopsis and/or description to your request.
Options requested: _____________________________________________________
_____________________________________________________________________
Exclusivity? YES ______ NO ____
Parody lyrics? YES ____ NO ____
If yes, please attach new lyrics to your request if currently available.
Production/Music budget: _________________________
Comments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Thank you for Your interest in this FLMG Title
Please complete this form and fax it, along with any additional elements
(i.e. film synopsis, parody lyrics) to the following number:
FLMG FAX:
(925) 472-0417
We will be in touch with you.
