Name of claimant
Author and title
Leave all above these lines blank
2 c. rec'd-
Affidavit rec'd-
Cl. A, XXc. No.- $ Cash No —
APPLICATION FOR COPYRIGHT — BOOK BY CITIZEN OR RESIDENT OF THE UNITED STATES.
Register of Copyrights, Washington, D. C. Date.
Of the BOOK named herein, first published after June 30, 1909, TWO complete copies of the best edition published on the date stated herein are hereby deposited to secure copyright, accompanied by the AFFIDAVIT required by section 16 of the Act of March 4, 1909, that the book has been produced in accordance with the manufacturing provisions specified in section 15 of the said Act. $1 (statutory fee for registration) is also inclosed. The copyright is claimed by the undersigned :
Name and address of ( " copyright claimant ( _
Author or authors_
If the work is anonymous or pseudonymous, it is not obligatory to state the name of the author.
Title of book_
_vol Price, j! . Date of publication exactly'
[Date when placed on sale, sold, or publicly distributed.] stated]
Send certificate of registration
Note. — This form is to be used only for BOOKS by otizbns or residents of the United States A sep- arate application card must be used for each separate work. No registration can be made unless copies are accompanied with a properly filled-out application card, statutory fee, and the required affidavit.
E^^ Failure to deposit copies bars suit for infringement and, if deposit of copies is nnt made after " actual notice," involves a fine of f loo, the payment of twice the value of the book, and the copyright becomes VOID. (over)
of(
