Republic THE COPYRIGHT ACT NO.

12 OF 2001
Kenya Copyright
Of Kenya THE KENYA COPYRIGHT BOARD Board
APPLICATION FOR REGISTRATION OF A COPYRIGHT WORK
FORM NO. CR 1

Applicants Details (Please fill in either as an individual(s) applicant or an organization but NOT both)

A Applicant is an individual(s)

Surname Middle Name First Name

ID Number PIN No.

Date of Application DD/MM/YYYY

B Applicant is an organization/Company

Organization/Company Registration Number PIN No.

Organization/Company Registered Name

Date of Application DD/MM/YYYY

Applicants Contact information

Physical Location P.O Box Postal Code

Email Address Telephone Mobile No.

Category of Applicant (Tick where appropriate) Author Producer/Publisher Licensee/Assignee

Agents Details (if any)

Surname Middle name First name

ID Number PIN No.

Agents Contact information

Physical Location P.O Box Postal Code

Telephone Email
Address

Page 1
of 4
Registration Form Serial

CR1
Copyright Work Details

Title of the Copyright work:

Category of Copyright Work (Tick where appropriate) Artistic Literary Sound Recording Audio Visual

Sub category of Copyright work: (Tick where appropriate)

(i) (For Artistic works only ;) Fine arts Applied arts

(ii) (For Literary works only ;) Books Computer programs Electronic databases Other writings

(iii) (For Sound Recordings works only); Musical Spoken words Others

(iv) (For Music works ;) Gospel Secular Patriotic Others

(v) (For performing arts only ;) Dramatic works Film/Movies Dances Cinematographic works

Date of fixation/reduction into material form: DD/MM/YYYY Language:

Abstract/Brief description of Copyright work:

Authorship Details

Main Authors: Surname Middle Name First Name

Authors Stage Name/Pseudo Name PIN Number

National ID Number

Authors Contact information

Physical Location P.O Box Postal Code

Telephone (Landline) Mobile Email

Phone Address

Page 2
of 4
Registration Form Serial

CR1
 Production Details

Name of Producer/Publisher
Email Date of Assignment
Or License (DD/MM/YY)
Country of production/publication:
National ID/Company Reg. No. Telephone (Landline)
Label Company: Gospel
Self Produced
Category of Production: Secular
Country of first Production Classification (Tick where appropriate)
Patriotic
Others
ISBN Number (Books Only)
Telephone
Category of Production (tick where appropriate) Label/Record Company Self Produced

Producers Contact information

Telephone (Landline) Mobile Phone

Email Address

I/We, the applicant(s) identified above apply for registration of the above copyright work as

I/We attach hereto two copies of the copyright work (where applicable).

We hereby declare that the copyright work, the subject of this application, is an original work.

BEFORE ME

COMMISSIONER FOR OATHS

Dated at . this .. day of . 20

Signature(s) .
Applicant(s)

Page 3
of 4
Registration Form Serial

CR1
 FOR OFFICIAL USE ONLY

Received By: Date Check List Tick submitted Documents

1. Two copies for each copyright work
Sign
2. Bank Slip
3. Authority Letter

Data Input By: Date

Sign

Date
Work Verified By:
Sign

Certificate Collected By: Certificate No. Issuing Officer

National ID No. Date

Sign Sign

Page 4
of 4
Registration Form Serial

CR1
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KEI{YA CO?YiIGHT IOARD

DECLARATION

I ............. Of P.O.BOX..............
........ceftify that I
have been informed suificiently to make a decision as to my registration and I fufther
understand as follows:

1. THAT Copyright protection only extends to expression of ideas and not the
ideas, concepts, phrases or slogans that may be contained therein or could be
better protected by other Intellectual Propefi Systems.

2. THAT Copyright registration herein is a voluntary system of notification and

rights are vested on creation as per established conventions, practices and the
Copyright Act cap 130.

3. THAT Registrationof a copyright work does not prevent other persons who
create similar works independently from marketing or practising the idea
contained in the Copyright work and I have been informed fufther that if my
work becomes subject of infringement It is my responsibility as the property
owner to initiate action against the infringer by way of civil or criminal action as
may be applicable

4. THAT such registration by the Kenya Copyright Board shall not constitute an
endorsement of the work or efficacy of the business practices or confirmation of
authorship by the registering person(s).

5. THAT I undeftake to use the Ceftificate issued by the Board for lawful purposes
and take all responsibility for all actions or use of the Ceftiflcate for purposes for
which it were not intended by law.

Signed

Mr./Mrs./Dr./Ps./Ms
(Full name)

On behalf of ............ ...(Firm/Co. ltd).

Date:

Original copy to the Kenya Copyright Board Registration file, copy to the Applicant.