Address :

If the company is located outside Quebec, is it registered with QST?
YES  NO

Is the company exempt from GST?
YES  NO
If so, please provide copy of the appropriate documents

Telephone :

Fax :

Web Site :

E-mail :

Contact :

Identification of the musical work:

Title :

Author(s) :

Composer(s) :

Publisher(s) :

Artist/performer :

Description of use of the musical work :

Timing of the musical excerpt used :
min.   sec.

Number of spots :

Advertisement timing :
30 sec.  60 sec.
Other (please specify) :

Duration requested for the licence :
(of 13 week cycles if possible)

Distribution :
television only  radio only  television and radio

Advertised product :

What is your budget :

Territory :
French Quebec  English Quebec
French/english Quebec  Canada
Other (please specify) :

Brief description of the advertisement (you may also join a short script) :

Additonal information :

What every producer should know :

Should you wish to change the lyrics of the work, please send us a copy of the new version so that we may submit it to the copyright owners for approval.

Should you reproduce the work directly from a pre-existing record, compact disc or cassette, the producer's master right must also be cleared. Upon request and if the information is available, we shall transmit to you their address and telephone number.