.

Office Use Only

Catamount Access Television Corporation
802-442-8868

TRT: _____:_____:_____
PREROLL: _____:_____

MEDIA PLAY REQUEST FORM

Please fill out form clearly! Form must be completed fully for the media to be processed.
Failure to properly complete form could result in program not being cablecast.

SERIES ITLE:_______________________________________________________________
EPISODE NAME:____________________________________________________________
TITLE:_________________________________________________________

MEDIA INFORMATION:

SERIES o

SINGLE PLAY PROGRAM o

MEDIA TYPE: DVD oVHS oSVHS o MPEG o
HEAD/TAIL TAGS: YES o NO o
PRE-ROLL: Seconds: _________________
TRT: ________ hrs _________ mins _________ secs
Preroll: :_____ Seconds TRT: ____:____:____

MEDIA INFORMATION CONTINUED:

CHANNEL: 15o16 o17 o
EPISODE PREMIERE DATE: ____________
LIVE PREMIERE: Y oN o

Scheduling is done on a daily basis. Your program will be scheduled within 3 weeks from the day it was submitted. Please specify if you have special scheduling considerations: ______________________________________________________________________________________________________________________________________________________________________________

SINGLE PLAY SCHEDULING INFORMATION:

The Vermont Media Exchange (VMX) is an internet based, statewide media network and is a way for your program to reach a larger audience.
oYES, I want my program uploaded to VMX and here is a brief description of my program:________________
________________________________________________________________________________________________________
oNO, do not upload my program to VMX.

VMX INFORMATION:

oYES, I will allow CAT-TV to make copies of my program upon request from the public.
o NO, Please do not make copies of my program with out notifying me first.
o I allow all my programs to be copied upon request as permitted by the form on file with CAT-TV.

PREMISSION TO COPY:

NAME: (please print) __________________________________________________________________________
EMAIL:______________________________________________ PHONE: ___________________________
YOU ARE THE: PRODUCER o(you/your organization arranged the original production & hold copyright)
PRESENTER o(the tape was orginally produced by others)

PRODUCER/PRESENTER INFORMATION:

I understand and agree, in accordance with CAT-TV Rules & Procedures, that by requesting this program to be cablecast, I am an Access Channel Programmer, and therefore I an fully responsible for content of the program when cablecast, whether or not I actually produced the program myself. I am (or the member organization I represent is) fully liable for all claims arising from unauthorized use of copyrighted material or any other charges of unlawful conduct and will hold harmless the Catamount Access Television Corporation (CAT-TV), its Directors, Officers, and staff from any such claim.
_________________________________________ _______________________________
Signature (Required) Today’s Date

REQUIRED SIGNATURE: