Authorisation Form - Payback 2014

Authorisation Form - Payback 2014 If you would like a representative to claim and to receive collective licensing royalties on your behalf then we require signed authorisation from you. Declaration - I confirm that I have authorised the party specified below (the ‘Authorised Representative’) to grant to the Design and Artists Copyright Society (‘DACS’) an exclusive* licence and a mandate to negotiate, claim and administer the secondary rights in my artistic works that I have authorised them to represent me for and to claim on my behalf a share of royalties arising from these rights collectively licensed by DACS as secondary uses** and annually distributed through Payback. - I also confirm that I have authorised the Authorised Representative to claim and receive on my behalf any royalty payments DACS has calculated as part of DACS’ Payback in respect of an authorised claim made on my behalf by the Authorised Representative, and to deduct any commission or fee as contractually agreed between me and the Authorised Representative. I further confirm that I have been made aware of the administration charges made by DACS and by the Authorised Representative (if applicable). I understand that DACS may contact me to validate the information I supply in this form. * Exclusivity is limited to the actual uses of the work claimed and paid for under DACS Payback scheme. This allows individual photographers and authorised representatives to license all other uses that are not covered by the Payback scheme. ** Secondary uses include the uses currently licensed by the CLA for the photocopying, scanning, printing and digital re-use and communication of works that are part of composite works, like books and magazines, and also licences governing document delivery services; the uses made under the educational recording licences currently operated by ERA and uses made under cable retransmission; but also similar international uses of works remunerated through levy systems etc. The full wording of the grant of rights is made available on the DACS website as part of the Payback Terms and Conditions and the online and paper Payback claim form 2014. I understand that by granting this licence I will become a Payback Member. My Payback Membership rights and responsibilities are governed by DACS’ Code of Conduct available on the DACS website. As a not for profit organisation, DACS retains a share of the royalties we collect to cover our costs. Since 2007, we have reduced the percentage of revenue we retain by 1% each year: from 25% in 2007 to 18% for Payback 2014. Please provide the name of the authorised representative claiming on your behalf: Name of representative Company name (if applicable) Address Telephone Email Please provide your details: Name Address Telephone Email Signed Date The information you provide is securely held by the Design and Artists Copyright Society (DACS) in the organisation’s contact database and will be treated securely and with sensitivity in accordance with the Data Protection Act 1998. This information will be used only by DACS for the purposes of confirming which parties are authorised to collect Payback on your behalf, save where necessary to administer payment of royalties to you or on your behalf or where otherwise permitted under the Data Protection Act 1998. Your personal data will not without your permission be disclosed to third parties. Data will not be disclosed to any external commercial organisation or third party without your individual permission. Under the terms of the Data Protection Act 1998 you can choose at any time not to receive communications from us in future. AUTHREP2014.

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