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Download Copyright Questionnaire
1. Please give the full name, address, telephone number, and type of business entity (i.e., individual, partnership or corporation, including state of organization or incorporation) of the copyright owner.
Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Congo, Democratic Republic of the
Congo, Republic of the
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Type of Business Entity
2. What type of work is this?
work of the performing arts (musical and dramatic works, pantomimes and choreographic works, motion pictures, and other audiovisual works, including computer program screen outputs)?
work of the visual arts (paintings, sketches, drawings, sculptures, maps, photographs, scale models, jewelry designs, fabric designs, architectural designs )?
nondramatic literary work (fiction, non - fiction, poetry, textbooks, reference works, directories, catalogs, a dvertising copy, compilations of information, computer programs)?
if this work is a contribution to a periodical or collection of various works, please give the title of this individual contribution and the title of the collection as a whole.
3. Describe the general character of this work ( e. g. , instructional video tape, musical recording, lithographic print).
4. Have copies of this work been publicly distributed or given to another for purposes of distribution to the public? If so, please describe the circumstances, and give the date (month/day/year) when this first occurred, and the location.
5. What is the exact title of this work?
6. What is the full legal name of the person who actually created this work (the author)?*
7. What is the date of birth of the author?
8. What is the nation of citizenship of the author?
If other, explain.
9. Was this work done anonymously or pseudonymously?
10. If done pseudonymously, to what pseudonym did the author attribute this work?
11. Was the work prepared by an employee acting within the scope of his/her employment or under a written agreement with the person who prepared the work?
12. If there is more than one author, what was each author's contribution to this work (e.g., text, photography, artwork, illustrations)?
13. Who owns the copyright in the work? If different from the author of the work, please explain how ownership of the copyright was obtained (e.g., copyright was assigned, author is the employee of the copyright owner).
Applicant owns copyright, as author is full-time employee and work was created within scope of duties.
Applicant owns copyright, as author signed written agreement assigning rights to work.
14. Has this work, or an earlier version of this work, been previously registered with the Copyright Office? If so, what is the Registration No. and date of registration? Why is another registration being sought?
New Registration sought because:
15. Is this work derived, or based on, a pre-existing work? (e.g., a translation or abridgment)? If so, how does this work differ from the pre-existing work (e.g., sculpture based on a drawing)?
16. Does this work consist of a collection of pre-existing materials or information which you have selected from a number of sources? If so, please describe this collection (e.g., compilation of 19th century political cartoons).
17. Do you wish to provide the Copyright Office with a license to make copies of this work for the blind and physically handicapped?
18. When was this work completed?
Acknowledgment of Confidentiality of Communications
At G. Philip J. Zies, PLLC, we take the protection of our client’s and potential client’s intellectual property seriously. Since there are dangers in communicating sensitive and/or proprietary information by email, we would like to provide you with the following information. Please read each of the items listed below carefully and then initial each item to indicate you understand and acknowledge each item. Please note that your failure to initial and acknowledge each item may limit our ability to communication with you regarding this matter.
I understand that communications between myself and an attorney, which would normally be subject to attorney‐client privilege, may be waived if a third party gains access to those communications.
I understand that third parties may have access to my attorney‐client emails when I send or receive emails via a public computer, such as a library or hotel computer, or via a borrowed computer.
I understand that a third party (i.e. my employer) may have access to my attorney‐client emails when I utilize my work computer.
If I must communicate with an attorney via a public computer or a work computer, I will only send confidential information via encrypted or password-protected documents, such as a password-protected Word® document or a password-protected .pdf document.
If I must communicate with an attorney via a public computer or a work computer, I will alert the attorney accordingly and request that the attorney only send confidential information via encrypted or password‐protected documents.
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