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12StepRadio.com Song Submission Form

12StepRadio.com is an independent, online, recovery music station. We are always looking for good music to play on the "air" and are very selective.
Submission does not guarantee that we will play your music. We do not return any submissions and we cannot guarantee that your titles will be selected, but if your title is chosen for airplay, we will contact you.

Please include lyrics and a separate form for each song submitted for airplay and mail to:

12StepRadio, Inc.
11452 El Camino Real, Suite 401
San Diego, CA 92130

Submitted by: ________________________________________________
Address: ________________________________________________
________________________________________________
________________________________________________
Email: ________________________________________________
Phone: ________________________________________________
Song Title: ________________________________________________
Number of Writers: [ ]One [ ] Two [ ] Three [ ] More
Is this song available for purchase on a CD? [ ] YES [ ] NO
Who is the performer? ________________________________________________
What is the CD called? ________________________________________________
Where can someone find it on the Internet? www.___________________
If your song is accepted for airplay, do you wish to make it available for purchase via downloading? [ ] Yes, I would like to make my song available.
[ ] No, I do not wish to make my song available.
[ ] I am undecided at this time.
If yes, please furnish the information regarding the song’s Publisher:
Please fill in the information for each person involved in the creation of the song. If there are more than 3 co-writers, please list any additional information in the "Notes" section below.
Writer No. 1
Name: ________________________________________________
Email: ________________________________________________
PRO Affiliation: [ ] ASCAP [ ] BMI [ ] SESAC [ ] None
Publisher Company Name: ________________________________________________
Phone: ________________________________________________
PRO Affiliation: [ ] ASCAP [ ] BMI [ ] SESAC [ ] None
Writer No. 2
Name: ________________________________________________
Email: ________________________________________________
PRO Affiliation: [ ] ASCAP [ ] BMI [ ] SESAC [ ] None
Publisher Company Name: ________________________________________________
Phone: ________________________________________________
PRO Affiliation: [ ] ASCAP [ ] BMI [ ] SESAC [ ] None
Writer No. 3
Name: ________________________________________________
Email: ________________________________________________
PRO Affiliation: [ ] ASCAP [ ] BMI [ ] SESAC [ ] None
Publisher Company Name: ________________________________________________
Phone: ________________________________________________
PRO Affiliation: [ ] ASCAP [ ] BMI [ ] SESAC [ ] None
Notes: ________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
None of the music contains any sampled materials or copyrighted property of third parties for which appropriate written consent from the third-party copyright holders has not been obtained. The music or any portions thereof do not and will not: (1) infringe on the rights of any nature of any third party (such as but not limited to copyright, or (2) violate any law, statute, ordinance or regulation. Writer will defend, indemnify, and hold harmless 12StepRadio.com, its officers, directors, shareholders, employees, agents and representatives from and against any and all claims, damages, liability, suits, proceedings, demands, court and other costs and expenses, including reasonable attorney's fees in any jurisdiction arising from or relating to the breach by writer of any of writer's warranties or representations, arising from or relating to 12StepRadio.com's use of the music as permitted by law.
Signature: ________________________________________________
Date: ________________________________________________
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