If you are registering: And the work is unpublished/published, send:

2-dimensional artwork a. And the work is unpublished, send

in a book, map, poster, one complete copy or identifying material
or print
b. And the work is published, send
two copies of the best published edition
3-dimensional sculpture a. And the work is unpublished, send
2-dimensional artwork
identifying material
applied to a T-shirt

b. And the work is published, send
identifying material
a greeting card, pattern, a. And the work is unpublished, send
commercial print or label, one complete copy or identifying material
fabric, or wallpaper
b. And the work is published, send
one copy of the best published edition
Check the box or boxes that describe your authorship in the material
you are sending. For example, if you are registering illustrations but
have not written the story yet, check only the box for 2-dimensional artwork.
Sign the application in black ink and check the appropriate box.
The person signing the application should be the author or his/her
authorized agent.
This space is optional. You may give the name and address of the
person or organization to contact for permission to use the work.
You may also provide phone, fax, or email information.
This space must be completed. Your certificate of registration will be
mailed in a window envelope to this address. Also, if the Copyright
Office needs to contact you, we will write to this address.
Complete this space only if you currently maintain a deposit account
in the Copyright Office.
You must give a title. If there is no title, state UNTITLED. If you
are registering an unpublished collection, give the collection title
you want to appear in our records (for example: Jewelry by Josephine, 1995
Volume). Alternative title: If the work is known by two titles, you also may
give the second title. If the work has been published as part of a larger work
(including a periodical), give the title of that larger work instead of an alterna-
tive title, in addition to the title of the contribution.
Give your name and mailing address. You may include your pseud-
onym followed by pseud. Also, give the nation of which you are a citizen or
where you have your domicile (i.e., permanent residence).
Give daytime phone and fax numbers and email address, if available.
Give the latest year in which you completed the work you are regis-
tering at this time. A work is created when it is fixed in a tangible
form. Examples: drawn on paper, molded in clay, stored in a computer.
If the work has been published (i.e., if copies have been distributed
to the public), give the complete date of publication (month, day,
and year) and the nation where the publication first took place.
USE THIS FORM IF
1. You are the only author and copyright owner of this work, and
2. The work was not made for hire, and
3. The work is completely new (does not contain a substantial amount
of material that has been previously published or registered or is in
the public domain).
If any of the above does not apply, you may register online
at www.copyright.gov or use Form VA.
NOTE: Short Form VA is not appropriate for an anonymous author who
does not wish to reveal his or her identity.
HOW TO COMPLETE SHORT FORM VA
Type or print in black ink.
Be clear and legible.
Give only the information requested.
Note: You may use a continuation sheet (Form __/CON) to list indi-
vidual titles in a collection. Complete space A and list the individual
titles under space C on the back page. Space B is not applicable to short
forms.
PRIVACY ACT ADVISORY STATEMENT Required by the Privacy Act of 1974 (P.L. 93-579)
The authority for requesting this information is title 17 U.S.C. 409 and 410. Furnishing the
requested information is voluntary. But if the information is not furnished, it may be necessary to
delay or refuse registration and you may not be entitled to certain relief, remedies, and benefts
provided in chapters 4 and 5 of title 17 U.S.C.
The principal uses of the requested information are the establishment and maintenance of a
public record and the examination of the application for compliance with the registration require-
ments of the copyright law.
Other routine uses include public inspection and copying, preparation of public indexes, preparation
of public catalogs of copyright registrations, and preparation of search reports upon request.
NOTE: No other advisory statement will be given in connection with this application. Please keep
this statement and refer to it if we communicate with you regarding this application.
The filing fee in the form of a check or money order (no cash) payable to
Register of Copyrights. (Copyright Office fees are subject to change. For
current fees, check the Copyright Office website at www.copyright.gov,
write the Copyright Office, or call (202) 707-3000 or 1-877-476-0778
(toll free)).
One or two copies of the work or identifying material consisting of
photographs or drawings showing the work. See table (right) for re-
quirements for most works. Note: Read Circular 40a for the require-
ments for other works. Copies submitted become the property of the
U.S. government.
Mail everything (application form, copy or copies, and fee) in one
package to: Library of Congress
Copyright Office-VA
101 Independence Avenue SE
Washington, DC 20559
Questions? Call (202) 707-3000 or 1-877-476-0778 (toll free). Recorded in-
formation is available 24 hours a day. Order forms and other publications
from Library of Congress, Copyright Office-COPUBS, 101 Independence Avenue,
SE, Washington, DC 20559, or call (202) 707-9100. Download circulars and
other information or register online at www.copyright.gov.
MAIL WITH THE FORM
4
Instructions for Short Form VA
For pictorial, graphic, and sculptural works
Name and Address of Author and
Owner of the Copyright
2
Year of Creation
3
Publication
4
Type of Authorship in This Work
5
Title of This Work
1
Signature of Author
6
Person to Contact for Rights/Permissions
7
Certifcate Will Be Mailed
8
Deposit Account
9
*17 U.S.C. 506(e): Any person who knowingly makes a false representation of a material fact in the application for copyright registration provided for by section 409, or in any written statement fled in connection
with the application, shall be fned not more than $2,500.
Form VA-Short Rev: 02 2012 Printed on recycled paper U.S. Government Printing Offce: 2012-xxx-xxx xx,xxx
Short Form VA
3 For a Work of the Visual Arts
UNITED STATES COPYRIGHT OFFICE
REGISTRATION NUMBER
8
Examined By

Correspondence

VA VAU
Effective Date of Registration

Application Received
Deposit Received
One Two
Fee Received
TYPE OR PRINT IN BLACK INK. DO NOT WRITE ABOVE THIS LINE.
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Deposit account #_____________________
Name ______________________________
___________________________________
___________________________________
___________________________________
___________________________________
9
Name
Number/Street/Apt
City/State/Zip
8
Certifcate
will be
mailed in
window
envelope to
this address:
DO NOT WRITE HERE Page 1 of ______pages
Copyright Offce fees are subject to change. For
current fees, check the Copyright Offce website
at www.copyright.gov, write the Copy right Offce,
or call (202) 707-3000 or 1-877-476-0778.
Privacy Act Notice: Sections 408-410 of title 17 of the United States
Code authorize the Copyright Offce to collect the personally identifying
information requested on this form in order to process the applica-
tion for copyright registration. By providing this information, you are
agreeing to routine uses of the information that include publication
to give legal notice of your copyright claim as required by 17 U.S.C.
705. It will appear in the Offces online catalog. If you do not provide
the information requested, registration may be refused or delayed,
and you may not be entitled to certain relief, remedies, and benefts
under the copyright law.
Title of This Work:
Alternative title or title of
larger work in which this
work was published:
Name and Address of
Author and Owner of the
Copyright:
Nationality or domicile:
Phone, fax, and email:
Year of Creation:

If work has been published,
Date and Nation of
Publication:

Type of Authorship
in This Work:
Check all that this author created.
Signature:
Registration cannot be completed
without a signature.

Name and Address of
Person to Contact for
Rights and Permissions:
Phone, fax, and email:
(Month, day, and
year all required)
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2
1
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3
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Phone ( ) Fax ( )
Email
a. Date ________________________________ ____________ ________________
Month Day Year
b. Nation
3-Dimensional sculpture Photograph Map
2-Dimensional artwork Jewelry design Text
Technical drawing
I certify that the statements made by me in this application are correct to the best of my knowledge.* Check one:
Author Authorized agent
x
Check here if same as #2 above.
Phone ( ) Fax ( )
Email