1.

Is the work to be registered

(a)

An original work?

(b)

Translation of a work in the public domain?

(c)

A translation of a work in which copyright subsists?

(d)

An adaptation of a work in the public domain?

(e)

An adaptation of a work in which copyright subsists?

2.

If the work is a translation or adaptation of a work in which copyright subsists:

(a)

Title of the original work.

(b)

Language of the original work.

(c)

Name, address and nationality of the author of the original work and, if the author is deceased, the date of his decease.

(d)

Name, address and nationality of the publisher, if any, of the original work.

(e)

Particulars of the authorization for a translation or adaptation including the name, address and nationality of the party authorizing.

3.

Remarks, if any.