Format--Notice of Intent to Enforce a Copyright Restored under the Uruguay Round Agreements Act (URAA) 1. Title:___________________________________________________ (If this work does not have a title, state "No title.") OR Brief description of work (for untitled works only): _________________________________________________________ 2. English translation of title (if applicable): __________________________________________________________ 3. Alternative title(s) (if any):____________________________ __________________________________________________________ 4. Type of work:_____________________________________________ _________________________________________________________ (e.g. painting, sculpture, music, motion picture, sound recording, book) 5. Name of author(s):________________________________________ __________________________________________________________ 6. Source country:___________________________________________ 7. Approximate year of publication:__________________________ 8. Additional identifying information:_______________________ __________________________________________________________ (e.g. for movies: director, leading actors, screenwriter, animator; for photographs: subject matter; for books: editor, publisher, contributors,subject matter). 9. Name of copyright owner:__________________________________ (Statements may be filed in the name of the owner of the restored copyright or the owner of an exclusive right therein.) 10. If you are not the owner of all rights, specify the rights you own:___________________________________________________ (e.g. the right to reproduce/distribute/publicly display/publicly perform the work, or to prepare a derivative work based on the work) 11. Address at which copyright owner may be contacted: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ (Give the complete address, including the country and an "attention" line, or "in care of" name, if necessary.) 12. Telephone number of owner:_________________________________ 13. Telefax number of owner:___________________________________ 14. Certification and Signature: I hereby certify that, for each of the work(s) listed above, I am the copyright owner, or the owner of an exclusive right, or the owner's authorized agent, the agency relationship having been constituted in a writing signed by the owner before the filing of this notice, and that the information given herein is true and correct to the best of my knowledge. Signature:_________________________________________________ Name (printed or typed):___________________________________ As agent for (if applicable):______________________________ Date:______________________________________________________ NOTE: Notices of Intent to Enforce must be in English, except for the original title, and either typed or printed by hand legibly in dark, preferably black, ink. They must be on 8 1/2 by 11 inch white paper of good quality, with at least a 1-inch (or 3 cm) margin.