If this page displays an entry form with no image sample visible, please categorise 'Entry form' and transcribe all fields except the height and width of the image sample.
If this page displays an image sample (the handwritten text in the form is partially or fully obscured or not present), please categorise 'Image sample' and enter ONLY the image number (if present) and the approx. height and width of the image sample.
If this page displays an entry form & an image sample (with ALL handwritten text & the image sample visible), please categorise ‘Entry form’ and transcribe all fields including the image number (if present) and the height and width of the image sample.
Page type: Image sample
Item number (top right of entry form): 109
Image number (corner of image sample itself - leave blank if not visible):
Date of registration stamp:
Date form completed (next to signature):
Description of work:
Date of Agreement or Assignment:
Names of Parties to Agreement or Assignment:
Name and Place of Abode of Proprietor of Copyright (use commas):
Name and Place of Abode of Author of Work (use commas):
Approximate height of image sample (cm): 18
Approximate width of image sample (cm): 20
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