Licensing - Wixen Music UK LTD

Please fill out this form in order for us to deal with your request as promptly and thoroughly as possible.

Requestors Details:

Your Name:

Date of Request: Your E-mail:

Company Name: VAT No:

Address:

City: Postcode: Country:

Phone: Fax:

Type of Request (please tick): Film Film Festival TV Video/DVD

Commericial/Advertising Other (Please Specify)

Song Title:

Writers:

Publishers: Artist:

(Please tick): Master Re-recording TV Artist Parody Lyrics Yes No

(If yes, please attach lyrics)

Background Vocal Background Instrumental

Visual Vocal Visual Instrumental Other (Please specify)

Territory: Term:

Scene/Use Description: Proposed Fee: £:

Media

Production Title:

Brief Synopsis:

Genre: Release Date: Production Budget: £:

Director: Duration of Total Production:

Producer: Writer:

Main Cast Members:

Other Songs/Music:

You can also download this form as a PDF here and fax or post this form to us:

First Floor • 12A St. George Mews • London • NW1 8XE

Fax. 02075860957