Ultra Electronic Active Media Group


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	ULTRA ELECTRONIC ACTIVE
	Media Group


	Licensing Request Form

	Please fill in this form and print. then mail to: Ultra Electronic Active, PO Box 2234 Paradise, CA 95967, USA. Questions? Please contact us!

Personal Data (*= required)

	Full Name*:
	Company Name:
	Job Title / Function:
	Phone # and extension:	area: phone#: ext.:
	Best Time to Contact You:
	Your E-Mail Address*:
	Your Organisation’s URL:
	Address:
	City:
	State / Province:
	Zip / Postal Code:
	Country (other than U.S.):

Media elements for which licensing is sought:
		•Existing Music media elements from this web-site: ----------> Please select:

		•Custom Created Music or media elements (we also provide graphics design!): Details about your requests: Other Media Elements: Digital images, photos, video, graphics, html, other please specify in box above.

Production / Product type for which licensing is sought for:
		Please choose your type of production for which you are seeking licensing: ** Details about your production:

Distribution Range of your Production / Product:

		Amount of Copies to be manufactured / distributed: Countries in which distributed: Worldwide Canada US Mexico Europe South America Middle East India Africa Israel Japan China Taiwan Russia Other
		Size of Audience / Viewership / Listenership:

License Types Requested by you (several may apply)
		Performance License New Media License Synchronization License Master Recording License Mechanical License Videogram License


License Terms sought:
		Detail: (especially important when seeking: exclusive or exclusive limited terms) -> All that are seeking else than “non exclusive” rights: Production time before publication: (weeks) (mos.) (years)

	Length of Terms: Desired length of terms: (days) (weeks) (mos.) (years) Product / Production Life: (days) (weeks) (mos.) (years)

Special Requirements / Coments:
		Please add any detail not covered above : (e.g. equipment manufacturer seeking licensing for samplers, sound library publishers; or anything you would wish to add)

*Planned budget for all here requested licenses:
(enter 0, if you request licensing terms to be granted free of charge.
- please explain below)

Please enter amount: *

Coments:

Thank you for your time!

You can also print and mail mail to: Ultra Electronic Active, PO Box 2234 Paradise, CA 95967, USA
Contact us for questions!