Sample Clearance Request

ສຳລັບການຂໍສິດໃຊ້ snippet ຂອງເພງເກົ່າ

Date: ____/____/______

1. REQUESTING PARTY / ຜູ້ຂໍສິດ

Artist / Producer Name
Label / Distributor	HupSub Music Publishing
Contact Email	laohupsubmusic@gmail.com
Contact Phone	+1 (302) 496-3326

2. ORIGINAL WORK (Sample Source)

Original Song Title
Original Artist
Original Album
Year Released
Original Record Label
Original Publisher
ISRC / ISWC (if known)

3. NEW WORK (Using the Sample)

New Song Title
New Artist
Producer
Planned Release Date

4. SAMPLE DETAILS / ລາຍລະອຽດ Sample

Portion sampled (timestamps)	From _____ to _____ (Total: ___ sec)
Element used	Drum break ☐ Vocal ☐ Melody ☐ Bass ☐ Other ☐
How it's used in new song
Modified?	No ☐ Pitched ☐ Time-stretched ☐ Chopped ☐
How prominent (intro/hook/background)

5. PROPOSED TERMS / ເງື່ອນໄຂສະເໜີ

Upfront Fee	$ ____________
Royalty Split — New Song	Original Owner: ____% / New Artist: ____%
Publishing Split	Original: ____% / New: ____%
Master Use Rate	Negotiable / Flat fee $______
Territory	Worldwide
Term	Perpetual

6. WHAT WE ARE REQUESTING

We respectfully request both of the following clearances:
✅ Master Use License — from the owner of the original sound recording
✅ Publishing License — from the original songwriter(s) / publisher

7. RESPONSE REQUESTED

Please respond within 30 days with:
☐ Approval at proposed terms
☐ Counter-offer with revised terms
☐ Decline (with reason if possible)

If approved, formal sample clearance agreement will be drafted and signed by both parties.

8. SIGNATURES

Requesting Artist / Producer
Name: _______________
Date: ____/____/______

HupSub Music Publishing
Phoumana Phensisanavong, CEO
Date: ____/____/______

9. ORIGINAL OWNER RESPONSE (To be completed by recipient)

☐ APPROVED at proposed terms
☐ APPROVED with modifications:
Upfront fee: $________ Royalty: ____% Other: __________
☐ DECLINED — Reason: ________________________________

Signed by Original Owner: ________________________________
Date: ____/____/______

HupSub Sample Clearance Office
Submitted by HupSub Music Publishing on behalf of artist
ສົ່ງໂດຍ HupSub Music Publishing ໃນນາມຂອງສິລະປິນ