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Mechanical License Request

*Please note:   Requests may take between 4-6 weeks for processing  

Fields marked with ** are required.

Date:
   
Title_of_Work: **
   
From Collection:
   
Concordia item number (six digit number with prefix of 97-, 98- or 99-): **
   

Author_Arranger:		 **
   
Publisher:        
   
Duration_of_Work:
   
Title_of_Project:
   
Artist:
   
Label: 
   
Configuration:
   
Number_of_Units:
   
Release_Date: 
   
Contact_Name: **
   
Contact_Address:  **
   
Contact_Phone: **
   
Contact_Fax:
   
Contact_Email: **
   
Licensee  Name: 
(if different from above)
   

Licensee Company:
   
Licensee Address:
   
Licensee Phone:
   
Licensee Fax:
   
Licensee Email:
   
*Enter security code:



 

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