Form V

APPLICATION FOR A COMPULSORY LICENSE FOR DISABLED PERSONS

(See rule 17)

To,

The Registrar of Copyrights/Secretary,

Intellectual Property Appellate Board,

Copyright Office,

New Delhi.

Sir,

1. In accordance with section 31 B of the Copyright ct, 1957 (14 of 1957), I hereby apply to the Copyright Board for a license to publish a published work for the benefit of disabled persons in accordance with the particulars given in the enclosed Statement.
2. I hereby undertake to abide strictly by the terms and conditions of the license, if granted to me.
3. I hereby verify that the particulars given in this form are true to the best of my knowledge, belief, and information and nothing has been concealed therefrom.

Place…………….

Date………………

 Yours faithfully,

………………….

(Signature)

STATEMENT

1. Full name of the applicant: ………………….

(In Block Letters)

2. Full address and nationality of the applicant: ………………….
3. Telephone/ Fax/E-mail: …………………………………….
4. Description of the work:

• Class of the work (Literary, Dramatic, Musical, Artistic, Cinematograph Film, Sound Recording);
• Title of the work;
• Full name, address, and nationality of the author and if the author is deceased, the date of his decease;
• Language of the work;
• Name, address and nationality of the publisher;
• Year of first and last publication;
• Country of first and last publication;
• Price of a copy of the work;
• If the copyright in the work is registered under section 45, the Registration Number, if known.
  5. Indicate the purpose for which the license is required.
  6. Specify the format in which the work is to be converted.
  7. Specify the nature of disability for which the format is required.
  8. Number of copies of work proposed to be published under the license applied for
  9. The Estimated cost of the work to be published
  10. Proposed retails price per copy of the work.
  11. Rate of royalty, which the applicant considers reasonable, to be paid to the copyright owner.
  12. Means of the applicant for payment of the royalty.
  13. Whether the prescribed fee has been paid and, if so, particulars of payment (give postal order/Bank Draft/Treasury Challan number).
  14. (a) Full name, address, and nationality of the person competent to issue a license;

(b) Whether the applicant has requested and has been denied authorization by the said person to publish the work for the benefit of a disabled person.

(c) If the applicant was unable to find the owner, whether he had sent a copy of the request by registered post to the publisher whose name appears on the work. If so, the date on which the copy was sent.

(d) Whether the author of the works has published the work for the benefit of the disabled persons and if yes the price of the copies.

15. Remarks, if any.
16. List of enclosures.

Place…………..…..

Date……………….

…………………

Signature