Name:
E-mail address:
Company or Organization:
School, College, or University Name:
business phone #:

Street Address1

Street Address2

City

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Nation
Zip Code/Postal Code

If you are interested in comissioning an original composition or arrangement please check the boxes below that apply:
Original Composition
Arrangement

Students or Educators seeking instruction or instructional material please check the boxes below that apply:
Students: (Lessons, Instruction, Piano Pieces)
Educator: seeking classroom instruction materials

If you are interested in Licensing or Distributing any of my works please check all that apply below:
Public Performance or Display (main-stream radio, tv or cable broadcast, public performance or display in a venue or on a web site)
Synchonization (placement of song in a TV show or Film Soundtrack.
Mechanical (song will be used on a product that is sold ( soundtrack CD, DVD's, Video etc.)
Net Radio Broadcast (song will be broadcast on net radio)
Educational (Educational product that will be sold such as text books, DVDs, CDROMs, software and other educational products, same as a mechanical license but discounted for educational institutions.)

Other Comments or questions?