MAIL WITH THE FORM

If you are registering: And the work is unpublished/published send:

• 2-dimensional artwork a. And the work is unpublished, send

 in a book, map, poster, one complete copy or identifying material

 or print b. And the work is published, send

two copies of the best published edition

• 3-dimensional sculpture, a. And the work is unpublished, send

• 2-dimensional artwork identifying material

 applied to a T-shirt b. And the work is published, send

identifying material

• a greeting card, pattern, a. And the work is unpublished, send

 commercial print or label, one complete copy or identifying material

 fabric, wallpaper b. And the work is published, send

one copy of the best published edition

Check the box or boxes that describe your authorship in the material

you are sending. For example, if you are registering illustrations but

have not written the story yet, check only the box for “2-dimensional artwork.”

Sign the application in black ink and check the appropriate box. The

person signing the application should be the author or his/her authorized agent.

This space is optional. You may give the name and address of the

person or organization to contact for permission to use the work. You

may also provide phone, fax, or email information.

This space must be completed. Your certificate of registration will be

mailed in a window envelope to this address. Also, if the Copyright Office

needs to contact you, we will write to this address.

Complete this space only if you currently maintain a deposit account

in the Copyright Office.

You must give a title. If there is no title, state “UNTITLED.” If

you are registering an unpublished collection, give the collection

title you want to appear in our records (for example: “Jewelry by Josephine,

1995 Volume”). Alternative title: If the work is known by two titles, you

also may give the second title. If the work has been published as part of a

larger work (including a periodical), give the title of that larger work instead of an alternative title, in addition to the title of the contribution.

Give your name and mailing address. You may include your pseudonym followed by “pseud.” Also, give the nation of which you are a

citizen or where you have your domicile (i.e., permanent residence).

Give daytime phone and fax numbers and email address, if available.

Give the latest year in which you completed the work you are registering at this time. A work is “created” when it is “fixed” in a

tangible form. Examples: drawn on paper, molded in clay, stored in a

computer.

If the work has been published (i.e., if copies have been distributed

to the public), give the complete date of publication (month, day,

and year) and the nation where the publication first took place.

USE THIS FORM IF—

1. You are the only author and copyright owner of this work, and

2. The work was not made for hire, and

3. The work is completely new (does not contain a substantial amount

of material that has been previously published or registered or is in

the public domain).

If any of the above does not apply, you must use standard Form VA.

NOTE: Short Form VA is not appropriate for an anonymous author

who does not wish to reveal his or her identity.

HOW TO COMPLETE SHORT FORM VA

• Type or print in black ink.

• Be clear and legible. (Your certificate of registration will be copied from your form.)

• Give only the information requested.

Note: You may use a continuation sheet (Form __/CON) to list

individual titles in a collection. Complete Space A and list the

individual titles under Space C on the back page. Space B is not

applicable to short forms.

PRIVACY ACT ADVISORY STATEMENT Required by the Privacy Act of 1974 (P.L. 93-579)

The authority for requesting this information is title 17 USC, secs. 409 and 410. Furnishing the

requested information is voluntary. But if the information is not furnished, it may be necessary to delay

or refuse registration and you may not be entitled to certain relief, remedies, and benefits provided in

chapters 4 and 5 of title 17 USC.

The principal uses of the requested information are the establishment and maintenance of a public

record and the examination of the application for compliance with the registration requirements of the

copyright law.

Other routine uses include public inspection and copying, preparation of public indexes, preparation

of public catalogs of copyright registrations, and preparation of search reports upon request.

NOTE: No other advisory statement will be given in connection with this application. Please keep

this statement and refer to it if we communicate with you regarding this application.

• The filing fee in the form of a check or money order (no cash) payable to Register of Copyrights. (Copyright Office fees are subject to

change. For current fees, check the Copyright Office website at

www.copyright.gov, write the Copyright Office, or call (202) 707-

3000.) — and

• One or two copies of the work or identifying material consisting of

photographs or drawings showing the work. See table (right) for requirements for most works. Note: Request Circular 40a for information about the requirements for other works. Copies submitted become the property of the U.S. Government.

Mail everything (application form, copy or copies, and fee) in one

package to:

Library of Congress

Copyright Office

101 Independence Avenue SE

Washington, DC 20559-6000

Questions? Call (202) 707-3000 [TTY: (202) 707-6737] between 8:30 a.m.

and 5:00 p.m. eastern time, Monday through Friday except federal holidays.

For forms and informational circulars, call (202) 707-9100 24 hours a day,

7 days a week, or download them from the Copyright Office website at

www.copyright.gov.

1 Title of This Work

2 Name and Address of Author and Owner

of the Copyright

3 Year of Creation

4 Publication

5 Type of Authorship in This Work

6 Signature of Author

7 Person to Contact for Rights/Permissions

8 Certificate Will Be Mailed

9 Deposit Account

4 Instructions for Short Form VA

For pictorial, graphic, and sculptural works
Complete this space only

if you currently hold a

Deposit Account in

the Copyright

Office.

Deposit Account #______________________

Name ________________________________

_________________________________________

_____________________________________________

_____________________________________________

Title of This Work:

Alternative title or title of

larger work in which this

work was published:

Name and Address of

Author and Owner of the

Copyright:

Year of Creation:

If work has been published,

Date and Nation of

Publication:

Type of Authorship

in This Work:

Check all that this author created.

.

Signature:

Name and Address of

Person to Contact for

Rights and Permissions:

Phone, fax, and email:

Phone ( ) Fax ( )

a. Date ___________________________________ ____________ _________________

Month Day Year

b. Nation

❑ 3-Dimensional sculpture ❑ Photograph ❑ Map

❑ 2-Dimensional artwork ❑ Jewelry design ❑ Text

❑ Technical drawing

I certify that the statements made by me in this application are correct to the best of my knowledge.* Check one:

❑ Author ❑ Authorized agent

x

Phone ( ) Fax ( )

Name ▼

Number/Street/Apt ▼

City/State/ZIP ▼

*17 USC §506(e): Any person who knowingly makes a false representation of a material fact in the application for copyright registration provided for by section 409, or in any written statement filed in connection with

the application, shall be fined not more than $2,500.

8

Certificate

will be

mailed in

window

envelope to

this address: OPTIONAL

TYPE OR PRINT IN BLACK INK. DO NOT WRITE ABOVE THIS LINE.

Examined By

Correspondence

❑

9

(Month, day, and

year all required)

5

6

7

2

1

4

3

Email

Registration cannot be

completed without a signature.

Email

Nationality or domicile:

Phone, fax, and email:

❑ Check here if same as #2 above.

DO NOT WRITE HERE Page 1 of ______ pages

Form VA-Short Rev: 07 ⁄ 2006 Print: 07 ⁄ 2006—30,000 Printed on recycled paper U.S. Government Printing Office: 2005-320-958/60,126

Copyright Office fees are subject

to change. For current fees, check

the Copyright Office website at

www.copyright.gov, write the Copyright

Office, or call (202) 707-3000.

3 Short Form VA

For a Work of the Visual Arts

UNITED STATES COPYRIGHT OFFICE

REGISTRATION NUMBER

VA VAU

Effective Date of Registration

Application Received

Deposit Received

One Two

Fee Received