RESIDENT PRODUCER

Cablecast Request Form - Series/Individual Program

PRODUCER:______________________________________________________ DATE:_____________

ADDRESS:______________________________________________________________________________________

PHONE:_______________________________ FAX:____________________ E-MAIL:____________________

SERIES Title:_________________________________ INDIVIDUAL PROGRAM Title:_________________________

LENGTH _____:_____:_____ TAPE FORMAT: _________INTENDED AUDIENCE:_________________

PROGRAM DESCRIPTION*: ______________________________________________________________________ _______________________________________________________________________________________________

*Non English programming must be accompanied by a translation.

I would like to cablecast the above series/individual program on PATC's Channel 20.I have been informed and understand

the series I will be cablecast for 6 months, at which time the series will be renewed or discontinued.

Scheduling Preference*

I am requesting a time slot for an Individual Program that is ______(Run time) and my schedule

preference is: DATE_______________ TIME_______________.

I am requesting a time slot for a series Program that is : (circle one) weekly bi-weekly monthly

My three preferences for a time slot are:

1. Day Time (AM-PM)

2. Day Time (AM-PM)

3. Day Time (AM-PM)

PATC will try to schedule your program as close as possible to one pf the above scheduling preferences.

Do you have written permission to use all material including music rights for cablecast? (Y/N)

Have you obtained all necessary releases? (Y/N)

I understand that the series may be limited in actual on-air due to the amount of locally produced programs.(Y/N)

I have been given and have read the Statement of Compliance and the Policies and Procedures as required by PATC. (Y/N)

Signature:_________________________________________________________ If you are under 18 years old. a parent or guardian is required to sing this agreement and the Statement of Compliance. ______________________________________________________________________________________________ *use a separate form for an individual program and a series program.