"#$%&'()* &+(',*&-*'#.

-./ /+$#,'* 0#&1

lnsLrucLlons:
1. llll up compleLely, preferably wlLh a LypewrlLer.
2. lf an lLem ls noL appllcable Lo you, please wrlLe 'n/A'.
3. ALLach all relevanL documenLs Lo Lhls form, lncludlng buL noL llmlLed
Lo: a) ueed of AsslgnmenL, 8lrLh CerLlflcaLe (for chlldren helrs), Marrlage CerLlflcaLe (for spouse helrs), Speclal ower of ALLorney (for
agenLs)
4. 1hls form ls noL for sale and MA? 8L reproduced.
3. CopyrlghL 8eglsLraLlon and ueposlL ls requlred by law for Lhe sole purpose of compleLlng Lhe records of Lhe naLlonal Llbrary (SecLlon
191 of 8epubllc AcL no. 8293).

.-*2&+ #0 3#&4
1lLle
1ype of Work
uaLe of CreaLlon lace of CreaLlon
"#$%&'()* #3.+&5, /+*-'6,
naLure of AppllcanL

! AuLhor / CreaLor ! Pelr ! Asslgnee (aLLach conLracL or deed of asslgnmenL)
! Lmployer (lf copyrlghL ls a resulL of Lhe employee's regularly-asslgned duLles)
name
(CorporaLlon or parLnershlp
name ln full, lf appllcable )

_______________________________________________________
Surname llrsL name Mlddle name
Address
(CerLlflcaLe of CopyrlghL and
8eglsLraLlon and ueposlL shall be
senL here)
_______________________________________________________
SLreeL Address 8arangay ClLy/MunlclpallLy
_______________________________________________________
SLaLe/rovlnce CounLry Zlp Code
Sex ! Male ! lemale
ClLlzenshlp
Allen CerLlflcaLe of
8eglsLraLlon (AC8) no.
(for non-llllplno resldenLs)

uaLe of 8lrLh / lncorporaLlon

Clvll SLaLus ! Slngle (lncludes ulvorced, Annuled or Wldowed) ! Marrled
1elephone no. Moblle hone no.
lax no. Lmall Address
-2*)#& 7 "&+-*#&5, /+*-'6,
(lf Lhe same as above, [usL leave blank. lf Lhere ls more Lhan one auLhor, please lndlcaLe all Lhe deLalls on a separaLe sheeL)
name


_______________________________________________________
Surname llrsL name Mlddle name
Address _______________________________________________________
SLreeL Address 8arangay ClLy/MunlclpallLy
_______________________________________________________
SLaLe/rovlnce CounLry Zlp Code
Sex ! Male ! lemale
ClLlzenshlp
Allen CerLlflcaLe of
8eglsLraLlon (AC8) no.
(for non-llllplno resldenLs)

uaLe of 8lrLh uaLe of ueaLh
(lf appllcable)

Clvll SLaLus ! Slngle (lncludes ulvorced, Annuled or Wldowed) ! Marrled
1elephone no. Moblle hone no.
lax no. Lmall Address

l declare LhaL all Lhe lnformaLlon provlded above are Lrue Lo Lhe besL of my knowledge:

________________________
SlgnaLure over prlnLed name
*# 8+ 0'66+/ 2$ 8% '$#$)6

llllng uaLe : ___________________
1lme : ___________________
Class of Work : ___________________
lee recelved : ___________________
AppllcaLlon no. : ___________________
C.8. number : ___________________
CerLlflcaLe no. : ___________________
rocessed by : ___________________

8Lu8LlC Cl 1PL PlLllnLS
_________________________) S.S.


AllluAvl1 Cl CWnL8SPl

l , , , of legal age,
(name) (naLlonallLy) (Clvll SLaLus)
resldlng aL ,
(lull Address)
afLer havlng been sworn ln accordance wlLh law, hereby depose and sLaLe LhaL:

1. AL Lhe daLe and Llme of Lhe execuLlon of Lhls affldavlL, copyrlghL subslsLs ln Lhe orlglnal
work wlLh Lhe followlng deLalls:

1lLle of Work : _______________________________________
uaLe CreaLed : _______________________________________
lace CreaLed : _______________________________________
1ype of Work : _______________________________________
AuLhor : _______________________________________
ClLlzenshlp : _______________________________________
CopyrlghL Cwner : _______________________________________

2. l am Lhe copyrlghL owner / represenLaLlve of Lhe copyrlghL owner of Lhe work descrlbed
above and l have aLLached Lhe necessary evldence Lo prove such facL,

3. l am execuLlng Lhls affldavlL and aLLachlng a Lrue copy of Lhe work descrlbed above ln
order Lo consLlLuLe affldavlL evldence ln accordance wlLh 218 of 8epubllc AcL no. 8293,

4. l have caused Lhe reglsLraLlon and deposlL of Lhe sald abovemenLloned work wlLh Lhe
naLlonal Llbrary of Lhe hlllpplnes ln accordance wlLh 191 of 8epubllc AcL no. 8293 for
Lhe purpose of compleLlng Lhe llbrary's records.


'. 3'*.+,, 3)+&+#0, l have hereLo afflxed my slgnaLure Lhls
(uaLe)
ln .
(lace)

________________
AfflanL

Subscrlbed and sworn Lo before me Lhls ln ,
(uaLe) (lace)
afflanL exhlblLlng Lo me hls/her
(ldenLlflcaLlon) (number)
lssued on aL .
(uaLe) (lace)

________________
noLary ubllc

uoc. no. _____,
age no. _____,
8ook no. _____,
Serles of 20___.


noLe: 1hls affldavlL shall be reproduced aL Lhe back of your CerLlflcaLe of CopyrlghL 8eglsLraLlon and ueposlL and shall be admlsslble as !"#$%
'%(#) evldence ln any proceedlng for an offense under Lhe ChapLer xvll of 8epubllc AcL no. 8293.