23 L.t. 1962 COPYRIGHT REGULATIONS, 2010 CINEMATOGRAPIIIC WORKS VIDEO FORMAT K C'INEMATO GRAPHY I I CELLULOID I NAME OF SCRIPT WRITER ADDRESS. NAME OF PRODUCER ADDRESS. I DO YOU HAVE ABOVE NAME CONSENT BEFORE FILMING THE SCRIPT YES (You are required to provide docu~entary NO evidence in all cases) (kindly provide the documentary agreements) Number of Performers. .. I, the undersigned, hereby certify that I am the (Tick one) CERTIFICATION: ( ) author/composer ( ) producer/publisher ( ) O\Hlcr of execJusive rig:ht OR ( ) authorised agent of: (name of author/other copyright claimant/exclusive right Hand\\ntten signature (x) .... Typed or printed name STAMP OF RECEl\'ING OFFICE Date Q\\l1er)