LICENSE APPLICATION
Request for Royalty and Rental fees for "Patience & Sarah"

Please Give Us Information About Your Organization

Organization Name: _________________________________

Theater or Auditorium Name: __________________________

Your Name: _______________________________________

Your Title: ________________________________________

Address: _________________________________________

City: __________________ State: ________ Zip Code: _____

Phone Number: (_____)______________________________

Fax Number: (_____)________________________________

E-mail Address: ___________________________________

Web site: ________________________________________

Last 3 Shows Performed: Royalty Paid: Score Rental: Set Rental:

1.) ___________________ _________ _________ _________

2.) ___________________ _________ _________ _________

3.) ___________________ _________ _________ _________

Information About Your Proposed Production of "Patience & Sarah"

Performance Dates:

First:_____/_____/_____ to Last: _____/_____/_____

# of Performances: ___________

# of Seats in Theater: _______ # Available Per Performance: _________

Ticket Prices: Low: ________________ High: ________________

I am interested in renting orchestral score and parts: yes______no______

I am interested in renting costumes: yes______no______

____________________________________________________________

print your name, your title, sign and date

By signing above you certify that you are the authorized agent for this

production and that the information you have provided above is accurate.

print this page, complete, and send to:

ONCE IN A BLUE MOON MUSIC PUB. CO.
PO Box 517, Brooklyn, New York 11217