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If this page displays an entry form with no image sample visible, please categorise as 'Entry form' and transcribe all fields except the height and width of the image sample.

If the page displays an image sample only (the text in the form is obscured or not present at all), please categorise as 'Image sample' and enter only the approximate height and width of the image sample in the relevant field below.

If the page displays an entry form and an image sample (with text fully visible), please categorise as ‘Entry form’ and transcribe all fields including the height and width of the image sample.

Page type: Image sample

Item number (top right of entry form): 540

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): 20

Approximate width of image sample (cm): 10