1. Name and surname of the publishing house proprietor:

2. Email address:

3. Contact phone number:

4. Name of the publishing house:

5. Website of the publishing house if applicable:

6. Address of the publishing house:

By completing and submitting this online form, you show a desire to establish business contacts with the Author.

7. We are interested in purchasing a licence for the book marked on your website as No.:

8.The License fee would be _____ €.:

9. If you are interested in purchasing a larger quantity of books, fill in the following column following the previous example (title of the
book and the license fee for it) %:

10. If the license fee for a particular book does not include a percentage of the later sale of that book for the author Kuka Mirosla, please state that in the license fee as well as in words: