Producer/Sponsor (Please print, sign and return with proof of address)
Program Title:	______________________________
Program Description:	______________________________
Program Length:	______________________________
Circle One:	Special Weekly Series Biweekly Monthly
Producer or Sponsor Print Full Name:	______________________________
Organization: (if non-profit):	______________________________
Non-Profit Tax ID (501c3) #:	______________________________
Full Address: Street, Town & Zip:	______________________________
Email:	______________________________
Home Phone:	______________________________
Work Phone:	______________________________
Cell Phone/Other:	______________________________
SIGNED (if under 18, must be signed by a parent or legal guardian)	____________________		Date:__________
Staff Use Only
Circle One to verify … Access User’s address verified by ID / Driver’s License / Utility Bill Other: _____________
Approved by:		____________________	Date:__________