SONG to license: ________________________________________________________

Respecting the copyright held by Mary Grigolia, composer,

I am purchasing (check appropriate):

_____ License to Copy, one-time  ($25)         _____ License to Copy, perpetual ($50)

_____ License to Perform ($50 or $1 per copy or per person in your choir)

Contact Name: ______________________________   

License Holder: ________________________________________________

Nature and size of proposed License holder (e.g., choir, congregation, school):

_______________________________________________________________________

How and when will the song be used? _____________________________________

_______________________________________________________________________

License holder address: _________________________________________________

_______________________________________________________________________

License holder telephone: _______________________________________________

License holder email: ___________________________________________________

License holder web-site/URL: ____________________________________________

By signing this application, signee agrees to use the songs as licensed and to include

copyright attribution on all copies, and on any program including this song.

Signed: __________________________________  Date: ____________________

Further, I wish to explore

_____ Permission to Publish                _____ Permission to Record

Describe: _______________________________________________________________

________________________________________________________________________