(Print this form, fill out and return with your video to LCTV, 29 Sheepscot Road, Newcastle, ME 04553)

Today's Date__________________

Program Title_____________________________________ Production Date:_______

*Program Length (be exact-to seconds):_______________ Preroll:________

Producer:________________________ Phone:__________ e-Mail: ___________________

Complete Address:________________________________________________________________________

Where was the program produced?______________________

Do you have written releases from all performers and all music and image copyrights and/or written permission from copyright holder? YES NO

If NO, please explain__________________________________________________________________

If you are requesting airtime for a live show please include on the reverse side detail of description of script, list of guests, subject and list of crewmembers. If this is a call-in show, also describe your method of screening calls.

You are responsible for identifying "adult content" (sex or violence) in programs you submit for airtime. Does your program contain any such material? YES NO

If yes, is it properly labeled? YES NO

Failure to comply will result in the suspension of your use of equipment and airtime.

Preferences for airtime (Max. twice a week for one month):

Time of Day:_______________ Day(s) of the week:_____________________________

Frequency: Twice a week___________Once a week_____________ Once a month_______________

Duration: One week _____ One month________

Upon signing this request, I certify that the above information is true and that the contents of the program to be aired will meet the requirements and laws of the FCC and State and local governing agencies.

Requester's Signature:______________________________________________________________________