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Request for Permission to Arrange Music

(Photocopy form as needed.)

Prepared by: Music Publishers’ Association of the US, and National Music Publishers’ Association, Inc. Modified by Central Virginia Community College for its use.



Part 1


This form is to be prepared in duplicate. After completing Part 1 and signing both copies where indicated, forward both to the publisher, who will complete Part 2 of the form and return it to you. If the publisher indicates a payment for the right you request, and if the conditions are agreeable to you, remit the amount to the publisher together with the original copy, signed by the publisher, whereupon the agreement will be completed.

CVCC faculty and staff must contact the Vice President for Finance and Administration prior to completing this form.


TO: _________________________________________________ Date: ______________
(Name of Publisher)

(Address of Publisher)

Dear Sir or Madam:

We hereby request your permission and nonexclusive license to arrange the following musical composition:

By: ________________________________________________ (words)
By: ________________________________________________ (music)
(hereinafter referred to as "The Arrangement")
1. The Arrangement will be for ____________________________________ in
                                                                        (type of arrangement)
__________________________________________. We will produce _______copies

(number of instrumental and/or vocal parts)

of The Arrangement for use and performance only by our _______________________

                                                                                                   (faculty, students, etc.)

for which no admission fees shall be charged or for performance otherwise exempt under the provision of the US Copyright Law.



Part 2

  1. No right to record or to reproduce additional copies is granted to us. We understand that if we wish to record The Arrangement, a separate license will be required. We agree not to distribute (except for use of copies as provided in Paragraph 1), sell, loan, or lease copies of The Arrangement to anyone.
  2. All copies of The Arrangement shall bear the following copyright notice:

    © 20__ (name of publisher), All rights reserved.

    and the words "Arranged by Permission" at the bottom of the first page of music of each part of The Arrangement. We will furnish you with a copy of The Arrangement upon completion.

  3. The College will have The Arrangement made by a person connected with us as our employee for hire, without any payment obligation on the Publisher’s part, and the signatures of both parties below shall assign to the Publisher all of the College’s rights in The Arrangement and the copyright in The Arrangement, together with the sole right of registering the copyright as a work made for hire, in the name of the Publisher or Publisher’s designee.
  4. Additional provisions (if applicable):
  5. In consideration of your permission to arrange, we will pay you $________________
    upon the granting by you of the permission requested.
  6. This license agreement sets forth our entire understanding and may not be modified or amended except by written agreement signed by both of us.

Vice President for Finance and Administration
Central Virginia Community College
3506 Wards Road
Lynchburg, Virginia 24502

By: _________________________________________________________
Vice President for Finance and Administration
Permission Granted:

By: _________________________________________________________

Permission denied because:
ο 1. Arrangement available for sale.
ο 2. Arrangement in process of publication for sale.
ο 3. May not be arranged because of contractual commitments.
ο 4. Other: ___________________________________________________________
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