L.1. 1962 31 COPYRIGHT REGULATIONS, 2010 NAME AND EMBLEM OF COLLECTING SOCIETY APPLICATION FOR PUBLIC PERFORMANCE LICENCE FORM 1 (regulation 37 (l)) No................ . lIWe ......................................................................of .......................................................................... . require a licence to use/perform cause to be performed audiovisual work/Drama/Concert or any other work which is protected by copyright at a .................................................................. . Uwe intend to organise the Performance at ............................................... :................... :.......... . : Date of P~formance , Nature of Performance Place of Performance Seating Capacity Gate Fee Time I1We agree that based on the licence given me by................................ (name of collectmg society) upon the above information which I certify to be true, I shaD pay ..................................... (name ofcollecting society) a rnin.imum deposit of.................................... . I agree that within 7 days of the performance I shall pay a balance based on ..................... . percent of the daily gate proceeds. I certifY that the above information is true to the best of my knowledge and belief. DATE: SIGNATURE OF APPLICANT (NAME AND ADDRESS OF COLLECTING SOCIE1Y)