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PRINT THIS FORM	COMPLETE IT	SIGN IT

ORDER FORM NAME: .............................................................................................................. POSTAL ADDRESS: .............................................................................................. . . . . . . . ........................................................................................................... . . . . . . . ....................................................................... POSTCODE: ................... E-MAIL ADDRESS (optional) ................................................................................... (Information given on this form will not be disclosed to a third party for marketing purposes)
Serial No	Title	Price
CYP8000	Personal recording wax cylinder	£15.00
	Post & packing free of charge	£0.00
	TOTAL	£15.00
Payment will be made online

I HEREBY DECLARE THAT:

The name of the work to be recorded is __________________________________________

The owner of the copyright of the work to be recorded is * ____________________________

_________________________________________________________________________

I have obtained the copyright owner's permission for this recording to be made

Signed: ______________________________

Date: _____________

* This may be your own name if you own the copyright