Section 1: Personal Details

* Required fields

Section 2: Jingle Details

Period covered by this form

Section 3: Media Used

Tick as many as applicable -

• Network TV
• Local TV
• Cable TV
• Satellite TV
• Radio

For TV and radio, please specify broadcast stations:

Section 4: Jingle Ownership Details

Please list the names and contributions of all authors/composers involved in creating this jingle. For example, if lyrics are included with this jingle and you did not write the lyrics, then please give us the author's name below or, where relevant, write 'agency lyrics'.

Section 5: Territories where the jingle has broadcast. Please check as many as applicable. We require evidence for all territories selected:

Please provide the specific broadcast details (eg. TV stations, period of broadcast, clock number). Without these details, there is a strong chance that the society will be unable to process the claim.

PRIVACY NOTICE

I have read and accept the terms of APRA AMCOS’ Privacy Policy (http://www.apraamcos.com.au/privacy-policy/) and consent to the handling of my personal information as described in those terms.

Australian Contact Information :
16 Mountain Street, Ultimo NSW 2007
Phone: 02 9935 7900
Fax: 02 9935 7970
Email: writer@apra.com.au
Web: www.apraamcos.com.au

New Zealand Contact Information:
Unit 113, Zone 23, 21-23 Edwin Street, Mount Eden
Phone: 09 623 4717
Email: nz@apra.com.au
Web: www.apraamcos.co.nz

APRA AMCOS has five offices in Australia and an office in New Zealand. Click here for further contact details for your area.