r­ . .... CD 0') N NAME AND EMBLEM OF SOCIETY FORM D (j ~ (regulation 37 (5) MONTHLY RETIJRNS OF WORKS USED OR PERFORMED Name of User or Perfonnance of Work Date: .............................. . Time-From: Title ofWork Type of use or Perfonnance ........................................... . To:................ Compiler/Producer: Work Origin ~- ----- -- -- Type of Work Creator/Composer/ ProducerlPublisher Author - ~ ~ ~ ~ ~ :::J ~ 0 ~ ~ ...... ~ I/We declare onlour honour that the return of works stated above as broadcasted were actually broadcast to the best of my I our knowledge and belief. DATE: ............................. MANAGER OF USER OR PERFORMER ..................,... SIGNATURE: RETURN COMPLETED FORM TO (NAME OF SOCIETY) WITHIN 7 DAYS OF THE USE OR PERFORMANCE W N