Page:Copyright, Its History And Its Law (1912).djvu/543

 AFFIDAVIT OF AMERICAN MANUFACTURE OF A^

COPYRIGHT BOOK.

Fill in the required statements to accord with the facts concerning the book named, and draw pen through such statements as are not intended to be made.

State of

County of_

Impression seal

here -r

•*>

( being duly sworn, depose 1 ' ( do solemnly affirm ) ■' "

(i) That I am the person claiming copyright in the book named herein.

(2) That I am the duly authorized agent or representative residing in the United States of the claimant of copyright in the book named herein.

(3) That I am the printer of the book named herein.

I further depose and say that, in so far as required by the Act of March 4, 1909,

the BOOK ENTITLED

of which two copies have been deposited, has been printed by_

_at_

( type )

from I plates made in the U. S. from type | ^et within the limits of the United

States by at ;

that the printing of the text of the said book was completed on ,

19 ; that the said book was published on, 19 ;

that the binding of the said book has been performed within the limits of the

United States by at

(Signature)-

, ( sworn to ), , ,. ,, Subscribed and -j affirmed \ ^^^°^^ '"^ *'* °^y °^ ' '9-

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