Copyright Prosecution Short Intake Form Are you filing your copyright as an individual or on behalf of a business?IndividualBusinessName First Last Contact Name First Last Email CompanyState of Formation (if known)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country PhoneWhat type of work do you want to protect?Nondramatic literary work (e.g. fiction, non-fiction, poetry, textbooks, reference works, directories, catalogs, advertising copy, compilations of information, computer program)?Work of the performing arts (e.g. musical and dramatic works, pantomimes and choreographic works, motion pictures, and other audiovisual works, including computer program screen outputs)Sound recording (e.g. recordings of music, drama, or lectures)Work of the visual arts (e.g. paintings, sketchings, drawings, sculptures, maps, photographs, scale models, jewelry designs, fabric designs, architectural design)Computer codeOtherWhen was this work completed? Date Format: MM slash DD slash YYYY 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.What is the exact title of this work? If this work is a contribution to a periodical or collection of various works, please give the title of the individual contribution and the title of the collection as a whole.Describe the medium in which the work is recorded or fixed. (i.e., instructional video tape, photograph, painting, musical recording).Does this work have multiple authors?YesNoList each author by name along with each author's contribution to this work (i.e., text, photography, artwork, illustrations)What is the full legal name of the person who actually created this work? (The author)What is the nation and citizenship of the person who actually created this work? (The author)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?YesNoWas this work created anonymously or under a pseudonym?YesNoWho owns the copyright in the work? If different from the author of the work, please explain how ownership was obtained (i.e., copyright was assigned, author is the employee of the copyright owner)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?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 (i.e., compilation of 16th-century maps and charts).Is this work derived, or based on, a preexisting work? (i.e., a translation or abridgment)? If so, how does this work differ from the pre-existing work (i.e., sculpture based on a drawing)?Please upload a scanned copy of the copyrighted material, if available.CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.