STATISTICAL SURVEY FORM- ANNUAL RESTRICTED COPY LICENSE

NOTE: This form is to be completed by the license holder and returned to Word Of Life International at the end of the license period. Word Of Life International reserves the right to inspect the records of the license holder should they fail to return this form. If overhead transparencies or other forms of visual projection are used the number of copies will be equivalent to the estimated size of the weekly congregation multiplied by the times used. All works copied and copied material reused during the license period must be included on this form, with total quantities shown, ie, Here I am Lord D. Schutte OCP 8 X 450 = 3600 You are required to distinguish between actual photocopying and transcription (reproduction by hand, typing etc), if an actual photocopy is made please TICK where requested. You will have to list the publisher of the songbook/hymn book photocopied from in the publisher column. This form maybe photocopied.

TITLE

COMPOSER

PUBLISHER

TICK

COPIES

Here I Am Lord(Example Only)

Dan Schutte

OCP

8 X 450=3600

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NAME OF LICENSE HOLDER

ADDRESS

LICENSE NUMBER 

EXPIRY DATE