Music Clearance Request

Please provide the following information about the music you need to clear, and MusInspection will contact you. All information is confidential.

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Name

Street Address

City/State/Postal Code

Phone

Rush Report

Yes No

I certify that if this work is reminiscent of any other known piece, group, or singer, or if I have been asked to create music similar to a pre-existing work, I will state those titles or artists here:

Was any reference track used?

Yes No

Were any samples used?

Yes No

If yes to the above two questions, please list references and/or samples:

Music to be cleared: List titles, times, TV/Radio, other identifiers

Link to downloadable music tracks:

Password if link is protected:

Agency

If PO required, Business Affairs contact:

Client

Music Company

Billing party name/address/contact information, if different from above:

I certify that the above information is true and correct to the best of my knowledge, and I have read and agreed to the MusInspection terms and conditions below.

I agree to remit payment for services rendered. If another party is responsible for payment, I have received approval from that party and they are listed above.

Terms and conditions