Publishing Services Application Form

Name *

First

Middle

Last

Legal name only

Email *

Phone

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Note: You must have a US based bank account to collect royalties form BMI / ASCAP

Role: *

Other Role

Do you control the rights to your music? *

PRO *

PRO Name

IPI / CAE #

Not your account #

Publishing Services Requested

Check all that apply

I agree with the Benton Publishing Administration Agreement. *

By clicking "I Agree" you warrant and represent that you are at least eighteen (18) years of age.

Click here to view agreement

Signature *

Date *