1. Is this copyright request for a work that has never before been copyrighted:

2. Is your work literary, meaning it is one of the following fiction, nonfiction, poetry:

3. Does this copyright request include images that belong to you
( If YES the images will be included in your copyright)
( If NO the images will NOT be covered by this copyright):

4. Do you plan to publish your work within the next month or so:

5. If you are planning to publish the work what is the anticipated date of publication
(If you do not plan to publish your work, only one copy is required by the Copyright Office)
(If you do plan to publish in the near future, the Copyright Office requires two copies of your work)
Month:

6. Year:

Title of your work:

Sub-title of your work (if applicable):

AUTHOR INFORMATION

7. Do you live in the United States:

First Name:

Middle Name or Initial:

Last Name:

Phone Number including Area Code:

Your primary email address:

Any secondary email address:

8. If your work has an ISBN number not previously used please type that here (without dashes):

9. Are you copyrighting this:

a. Or if copyrighting in the name of an Organization type that name here:

b. Or if you are copyrighting it in your DBA (Doing Business As) type that here:

10. Type your name, if not previously entered in author information above:

11. If copyrighting in the name of your organization, what is your relationship to them
(For example: an employee, designated agent):

12. List the physical address of the Author's Location
Street Address:

City:

State:

Zip Code:

Phone Number including Area Code:

Best email address to reach you: