Identification of the applicant

Name or corporate name and address:

Telephone:

Fax:

E-mail:

Publisher or publisher name:

Description of document filed:

International Standard Number (ISBN):

Name, First names of authors (main author, translator, adapter, illustrator etc):

Title of the book:

Collection title and number in this collection:

Edit Character

□ Novelty

□ New edition

□ Reprinting

Age groups

□ 0 to 2 years

□ 2 to 6 years

□ 6 to 9 years

□ 9 to 12 years

□ 12 to 14 years

□ 14+

Name or business name and address of the printer:

Date of public availability:

Figure declared in the draw:

Number of copies deposited (mandatory deposit in 2 copies):

DATE: