Personal Information
First Name:
Middle Name:
Last Name:
Suffix:
All A/K/A/s:
Driver's License #:  State:
Social Security Number:
Date of Birth:
 
Home Address
Address:
Address Cont.:
City:
State:
Zip:
Country:
 
Contact Information
Home Phone:
Work Phone:
Cell Phone:
Fax:
Email:
Emergency Contact Name:
Emergency Contact Phone:
 
Royalty Information
Please list all royalty sources (performing rights societies, music publishers, record labels, etc.)

Royalty Source:
Member/Account Number: #
Approximate Income: $
Account Name:
 
Royalty Source:
Member/Account Number: #
Approximate Income: $
Account Name:
 
Royalty Source:
Member/Account Number: #
Approximate Income: $
Account Name:
 
Royalty Source:
Member/Account Number: #
Approximate Income: $
Account Name:
 
Main Royalty Sources: (check all that apply)
Radio  Mechanicals  TV  Film  International  Other

Names of your own publishing companies:

Biggest songs, etc. in your catalogue:

Any advances? Yes No   By whom:
Any assignments? Yes No   To whom:
Any liens? Yes No   To whom:
Any levies? Yes No   To whom:
 
Loan Information
If borrowing, Loan Request: $
If selling, reasonable Sale Request: $
 
How did you hear about us?  
 
Authorizations/Representations

Checking this box signifies that (i) Royalty Advance Funding and/or its affiliated companies (collectively "RAF") is authorized to do any and all due diligence it deems necessary to evaluate my loan / sale request; (ii) RAF is authorized to request and to receive all my account information from music publishers, performing rights societies, record labels, credit bureaus, and any other organization that would have information on my royalties and credit; and (iii) I represent and warrant that the above statements are true to the best of my knowledge.