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If the page displays an image sample only, please enter only the approximate height and width of the image sample in the relevant field below.

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Page type: Image sample

Item number (top right of entry form): 484

Date of registration stamp:

Date form completed (next to signature):

Description of work:

Date of Agreement or Assignment:

Names of Parties to Agreement or Assignment:

Name and Place of Abode of Proprietor of Copyright (use commas):

Name and Place of Abode of Author of Work (use commas):

Approximate height of image sample (cm): 25

Approximate width of image sample (cm): 18