Bmi Clearance Form – Fill Out and Use This PDF

INSTRUCTIONS

Enter applicable information on reverse side and RETURN TO BMI CLEARANCE DEPARTMENT. DO NOT enter information in the shaded area.

TITLE	Enter complete title of work you are submitting for clearance. If also known under another title, please indicate
	aka (also known as) and enter other title. (ONLY ONE WORK PER FORM)
	If this work is based on a Public Domain work, enter ORIGINAL TITLE, WRITER AND SOURCE. A LEAD
	SHEET OR RECORDING MUST BE SUBMITTED WITH THIS CLEARANCE FORM IF THIS WORK IS
	BASED ON A PUBLIC DOMAIN WORK.
	If this work was written for a Full Length Feature Motion Picture or a Film made for TV, or a Broadway or Off-
	Broadway Show of Infomercial, check appropriate box and give complete title of Motion Picture, TV Film,
	Show or Infomercial.
WRITER(S)	Enter complete name and address of each writer. If pseudonym, enter complete name of writer under his
	pseudonym. Last Name first followed by First Name and Middle Name or Initial. Enter Social Security No.
	of each writer.
	Enter the affiliation (PERFORMING RIGHTS ORGANIZATION) for each writer.

PERCENTAGE Enter share of each writer. Writers’ shares should total at least 100%.

SHARES

WRITER(S)

PUBLISHER(S) Enter complete name of all publishers and co-publishers.

If publisher acquired this work from a publisher outside the United States, enter complete name of the original foreign publisher and the territories for which sub-publishing rights were acquired.

Enter the affiliation (PERFORMING RIGHTS ORGANIZATION) for each publisher.

PERCENTAGE Enter share of each publisher. Publishers’ shares should not exceed 100%.

SHARES

PUBLISHER(S) IF NO RIGHTS HAVE BEEN ASSIGNED TO ANY PUBLISHER, CHECK THE BOX PROVIDED. IN SUCH

CASE FULL PUBLISHER SHARE WILL BE DIVIDED BETWEEN WRITERS IN THE SAME PERCENTAGE AS WRITER SHARES.

If part of publisher share has been granted, indicate percentage due to publisher and percentage retained by writer(s).

SPOKEN	Spoken word material with a musical background will be cleared only if the music is original (not based on a
WORD	Public Domain work) and if a substantial part of the recording contains background music. A recording must
MATERIAL	be submitted with this Clearance Form if this is spoken word material.
RECORD	If this work has been recorded, enter the record label and number, artist and date or future date of release.
DATE	Enter the date you are submitting this work to BMI.
SIGNATURE	This form must be signed by an affiliated writer or an authorized representative of the submitting
	publisher.

IF ALL OF THE ABOVE INSTRUCTIONS ARE NOT FOLLOWED THIS WORK WILL NOT BE REGISTERED FOR LOGGING PURPOSES AND THE FORM WILL BE RETURNED TO YOU FOR CORRECTION OR COMPLETION.

CLEARANCE TERMS

THE RETURN OF A CLEARANCE CONFIRMATION STATEMENT INDICATES THAT THE WORK LISTED ON THE REVERSE SIDE HAS BEEN CLEARED.

A writer submitting this form warrants and represents that (s)he is the writer or co-writer of the work to the extent indicated and that (s)he has not acquired his or her interest in such work by virtue of purchase or assignment from the writer or writers thereof.

Please note that in the event that a work cleared is published or recorded with lyrics which we, in our sole judgement, regard as unsuitable for broadcast use or with musical or lyrical material which we, in our sole judgement, regard as an infringement, we reserve the right at any time to exclude this work in its entirety from the provisions of our agreement and to withdraw the clearance.

We bring to your attention that in the event a clearance form submitted does not properly indicate in the space provided therefor that a work is based on public domain source, we reserve the right, if at any time such work is found to have a public domain source, to allocate to such a work a percentage of the normal logging credit or, in the case of a work having little or no original material, to give no logging credit to such work.

Michael Tortora

Clearance Dept.