I hereby certify that for each of the work(s) listed above, I am
the copyright owner, or the owner of an exclusive right, or the
owner's authorized agent, the agency relationship having been
constituted in a writing signed by the owner before the filing of
this notice, and that the information given herein is true and
correct to the best of my knowledge.

Signature-------------------------------------------------------------

Name (printed or typed)-----------------------------------------------

As agent for (if applicable)------------------------------------------

Date:-----------------------------------------------------------------

(ii) Optional but essential information:

(A) Type of work (painting, sculpture, music, motion picture, sound
recording, book, etc.);

(B) Name of author(s);

(C) Source country;

(D) Approximate year of publication;

(E) Additional identifying information (e.g. for movies: director,
leading actors, screenwriter, animator; for photographs or books:
subject matter; for books: editor, publisher, contributors);