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Copyright Registration Disclosure Form

This form should be used if you want to register a copyright with the United States Copyright Office. You may fill-out this form and then return it to us via email by pressing the “submit” button at the end of this form. Alternatively, you may print-out this form, fill-in the requested information and return it to us by U.S. post office mail or facsimile.

* Required Field
*Your Name:
(first, middle, last)
Home Address:
Mailing Address:
City:
City:
State:
State:
Zip:
Zip:
*Home Phone:
Other Phone:
Fax:
*E-mail:
I.
*Describe the work of authorship you want registered as a copyright (for example, book, magazine article, music, computer program, sculptured work, etc.):
II.
In what year did you first publish your work of authorship?

III.
Have you previously applied to register a copyright for the same or similar work with the United States Copyright Office or with a foreign copyright office?    

Our Assurance of Confidentiality
Premier IP Protection, LLC hereby agrees that any information pertaining to copyright information provided by the owner(s) of the copyright named in this Copyright Registration Disclosure Form will not be revealed, used, disclosed, sold, or transferred without the express authorization of the owner(s) of the copyright, except if required by court order.

For Premier IP Protection, LLC:
Walter S. Stevens
Walter S. Stevens, Esq.
Manager Member

Copyright Owner's Statement
By submitting this Copyright Registration Disclosure Form and any other information pertaining to the copyright, I acknowledge that Premier IP Protection, LLC is accepting this information for review purposes only.  I understand that any comments that I receive based upon this review are based upon a limited analysis and is neither meant nor understood to be a conclusive legal opinion.  Further, I agree that Premier IP Protection, LLC cannot be held responsible for any recommendations based upon the review of the information herein and cannot be held responsible for the return of any submitted materials.  Even if no signature(s) for the owner(s) of the copyright is/are included in the submitted form, I/we acknowledge that the submission of this Copyright Registration Disclosure Form shall indicate my agreement to this Copyright Owner’s Statement.

Signature**:
Date

** There is no need sign this form, if returning this form by email. It will be assumed that the completed form is from the individual whose name appears above.

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