Laserfiche WebLink
l J <br />� �j LOCAL GOVERNMENT ENTITIES <br />A s C A P 2012 Report Form <br />Account Number: I I I I I Premise Name: I I I I I I I I I I I I I I I I I <br />SCHEDULE A: Base License Fee (Due upon execution of Agreement and within 30 days of the Agreement's Renewal Date.) <br />Population Size: = <br />(Per current U.S. Census Data) <br />Base License Fee: $ ,m <br />(Please refer to Rate Schedule) <br />SCHEDULE B: Special Events* (Report and Payment due 90 days after the conclusion of each Special Event) <br />v • . <br />° - <br />e• vv <br />m <br />° <br />u•vm <br />mmmmv <br />vnuv <br />• <br />• <br />a <br />vvvvuvvveiv <br />�vvvvavv¢vu <br />e• nv <br />v • � v <br />• <br />- -• <br />-" <br />vveevmvv <br />m•avvw <br />R ° va <br />v imnv <br />° iin ° <br />° v <br />v • <br />vvv <br />vm um <br />i - <br />vv v <br />vm <br />vvme <br />- - <br />> _ <br />m <br />Daum <br />- '- •- <br />a•mniims <br />esvvvv <br />v . • <br />gg <br />a veiisiiias <br />• vuu <br />amvmvavvsmvamanvvvvvvvvmvvvvvvv <br />°f vv ° ice amii <br />° ni000iose <br />° viavev <br />-••' <br />vvaaea•vvv <br />vvamvvuvvv <br />�a v� va ° ° • <br />a II• m <br />v g <br />w aFi <br />mswv�a <br />vv <br />• ie ° �iaec ° a <br />wvm••vm <br />msuvv <br />'aami <br />° a <br />° ° v ° v <br />_ <br />3 • •• <br />oa • n in <br />m 'M <br />maaav <br />o•h•vvae•vnmrmva <br />NO <br />mmm <br />vv <br />v m umuvv <br />Kano <br />° • �6 <br />° aen <br />° �'an° .Rr <br />° gv ° <br />• <br />Addre <br />Phone <br />Addre <br />001 <br />• - <br />Accoun <br />• <br />1 <br />— Special Events" means musical events, concerts, shows, pageants, sporting events, festivals, competitions, and other events of limited <br />duration presented by LICENSEE for which the "Gross Revenue" of such Special Event exceeds $25,000. <br />""Gross Revenue" means all monies received by LICENSEE or on LICENSEE'S behalf from the sale of tickets for each Special Event. If <br />there are no monies from the sale of tickets, "Gross Revenue" shall mean contributions from sponsors or other payments received by <br />LICENSEE for each Special Event. <br />SCHEDULE C: State Muni .foal and/or County Leaaues or State Associations of Attorneys <br />Report Year: Annual License Fee: $320.00 (Due within 30 days of Renewal Date.) <br />Total Fees Reported From Any or All of Schedules A, B or C: $ 1 1 I - TT - 1- M <br />Contact Person & Title <br />Phone Number: -� -� Ext: Fax Number: <br />� -� -� <br />Email: F W ebsite: <br />I certify the above information is true and correct. <br />Dated: m / m <br />Signature: <br />L ASCAP, Po Box 331608 -7515, Nashville, TN 37203 -9998 1- 800 -505 -4052 615- 691 -7795 (FAX) <br />Epayment Websites http: / /vvww.ascap.com /mylicense or http: //wvnv.ascap.com <br />