Educational Program, Work and Other Subject-matter Record-keeping Regulations (SOR/2001-296)

Educational Institution identifier (if assigned):

Name and address of institution:

Contact name:

Telephone: Facsimile: E-mail:

Details of Program, Work or Subject-matter

Copy identifier:

Title of program, work or subject-matter:

Other identifying information: [e.g. episode title, subject, segment description, song title(s)]

Duration of segment copied: minutes

Date of broadcast (yy/mm/dd): Time of broadcast:

Name, network, call sign or other identifier of the broadcaster:

Record of Public Performances

(List only performances for which royalties are payable)

yy/mm/dd yy/mm/dd

(Use separate sheet to list additional performances)

Record of Destruction

I certify that the copy of the program, work or subject-matter identified above has been destroyed.

Name: Title:

Signature: Date of Destruction (yy/mm/dd):