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Canadian Intellectual Property Office Symbol of the Government of Canada


Application for Registration of a Copyright

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For assistance in completing the form, please refer to the "Instructions" sheet. Please print.

1. Title of the work

2. Category of the work
Select the category or categories that best describe your work.
Literary   Musical   Artistic   Dramatic  


3. Publication
A. The work is published   B. The work is unpublished

Date of first
publication
 Y     M    D 
Place of publication:
City/Town (optional)

Prov./State (optional)

Country
__   __   _______________________________________________


4. Author(s)
Same as owner(s) (if author is "same as owner" go to section 5 - if more than one author, please attach a list of names and addresses of all the authors)
Family name First name Initial If deceased,
date of author's death:
_________________ _________________ ____ Y___ M___ D___
Address
City/Town Prov./State Country Postal/ZIP code
_____________ ____________ ____________ ____________



5. Owner(s) - (If more than one owner, please attach a list of names and addresses of all the owners)
A. Family name First name Initial
______________________ ______________________ ___
OR
B. Name of corporation
Address
City/Town Prov./State Country Postal/ZIP code
_____________ ____________ ____________ ____________

6. Declaration
The applicant declares that he/she/it is:
A) Author of the work B) Owner of the copyright in the work C) An assignee of the copyright D) A licensee of copyright in the work


7. Agent (if applicable)
A. Family name First name Initial
______________________ ______________________ ___
OR
B. Name of firm
Address
City/Town Prov./State Country Postal/ZIP code
_____________ ____________ ____________ ____________
Telephone no. Fax no. (if available)   E-mail (if available)
(____)_____________ (____)______________ ______________________


8. Credit card payment
VISA MasterCard American Express
Credit card number:______________________ Expiration date:______________


(For Canadian Intellectual Property Office use only)


All correspondence should be
addressed to:
Copyright Office
Canadian Intellectual Property Office
Industry Canada
Place du Portage I
50 Victoria Street
Gatineau, QC  K1A 0C9		   Telephone: (819) 997-1936
Facsimile: (819) 997-6357
Internet address: www.cipo.gc.ca/copyrights
E-mail: cipo.contact@ic.gc.ca

Please do not send copies of your work.

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