Anda di halaman 1dari 2

TO BE FILLED UP BY IPOPHL

Filing Date: ___________________


Time
: ___________________
Class of Work : ________________
Fee received: _________________
Application No.: ________________
O.R. Numbe: __________________
Certificate No. :_________________
Processed by :_________________

COPYRIGHT
REGISTRATION AND
DEPOSIT FORM

Instructions:
1. Fill up completely. If an item is not applicable to you, please write
N/A.
2. Attach all relevant documents, including but not limited to: Deed of Assignment, Birth Certificate (for children), Marriage
Certificate (for spouses), Special Power of Attorney (for agents)
3. This form is not for sale and MAY BE reproduced.
4. Copyright registration and deposit is required by law for the sole purpose of completing the records of the National
Library (Section 191 of Republic Act No. 8293).
NATURE OF WORK
Title
(name given to a specific
work)
Type of Work
(book, musical composition,
etc.; see works included in
No. 6 of Guidelines for
Copyright Registration &
Deposit)
Date of Creation
(day the work was finished)
Nature of Applicant

Name
name of a natural person,
or a juridical person such as a
corporation or partnership, or
an organization)
Address
(address where the Certificate
of Copyright Registration and
Deposit shall be sent)
Sex
Citizenship
(nationality)
Date of Birth / Incorporation
(for juridical persons, date of
registration)
Civil Status
Telephone No.
Fax No.

Place of Creation
(place the work was done)
COPYRIGHT OWNERS DETAILS
Author / Creator (natural person who made the work)
Heir (spouse, child, or person named as heir in a will)
Assignee (person to whom the right was assigned)
Employer (person employing an author who made the work as a result of regularly-assigned
duties)

(full

Surname

First Name

Street Address

Barangay

State/Province
Male
Female

Country

Middle Name

City/Municipality
Zip Code

Passport No.
(for non-Filipinos)

Single (includes widowed, annulled or divorced)


Married (includes separated)
Mobile Phone No.
Email Address
AUTHOR / CREATORS DETAILS
(leave blank if the author is the copyright owner; if more than one author, indicate all the details in a separate sheet)
Name
Surname

First Name

Middle Name

Address

Sex
Citizenship
Date of Birth

Street Address

Barangay

State/Province
Male
Female

Country

Civil Status
Telephone No.
Fax No.

City/Municipality

Passport No.
Date of Death
(If applicable)
Single

Married
Mobile Phone No.
Email Address

I declare that all the information provided above are true to the best of my knowledge.
____________________________
Signature over printed name

Zip Code

REPUBLIC OF THE PHILIPPINES }


_________________________ } S.S.
AFFIDAVIT OF OWNERSHIP
I,

(Name)
residing at

, of legal age,

(Nationality)

(Civil Status)

__

(Full Address)
after having been sworn in accordance with law, hereby depose and state that:

1. At the date and time of the execution of this affidavit, copyright subsists in the original work with the
following details:
Title of Work
Date Created
Place Created
Type of Work
Author(s)
Citizenship
Copyright Owner

:
:
:
:
:
:
:
:
:

2. I am the copyright owner/ one of the copyright owners/ representative of the copyright owner/s of the
work described above;

3. I have caused the registration and deposit of the said abovementioned work with the National Library of
the Philippines in accordance with 191 of Republic Act No. 8293 for the purpose of completing the
librarys records;

4. I am executing this affidavit and attaching a true copy of the work described above in order to constitute
affidavit evidence in accordance with Sec. 218 of the Intellectual Property Code of the Philippines
(Republic Act No. 8293).

in

IN WITNESS WHEREOF, I have hereto affixed my signature this


.
(Place)

(Date)

Affiant
in

SUBSCRIBED AND SWORN to before me this


(Date)
me his/her
(Government-issued ID)
.
(Place)

(Number)

, affiant exhibiting to
(Place)
issued on

at
(Date)

Notary Public
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 20___.

Note: This affidavit shall be reproduced at the back of your Certificate of Copyright Registration and Deposit and
shall be admissible as prima facie evidence in any proceeding for an offense under the Chapter XVII of Republic
Act No. 8293.