WHAT'S ON
PLAYBACK APPLICATION
Program Title
 
Organization affiliated with program (if applicable)
 
Does this organization have 501(c)3 non-profit status?  
 
Short description of program (for website and other program listing)
 
Please check a category that best applies to your show



































 
Please check one for your show or any episodes of your series  

 
Type of playback slot you are requesting  


 
Series Only: Is this a new show, a renewal of an existing series, or a request to change timeslots  

 
Length of Show  

 
Do you plan to do a live show or submit prerecorded tapes?  
 
Whose equipment and/or facilities (such as camera, editing, and studio) do you plan to use to produce your show?  


 
If you will not be produng the show yourself, please provide the name, city, and state of the person of organization that will:
 
The following information is for internal purposes only.
 
First Name
 Last Name
Organization Name
Mailing Address
Home Number (415) 555-5555
 Business Number (415) 555-5555
   
FAX Number (415) 555-5555
 Email Address
Home Address (if different from mailing address)
 
Website Address
 
Would you like your website published on the station's website?  
 
Viewers must be able to contact you in order to give you feedback, which may include questions, praise, and cornplaints. You must provide(1) a name and (2) at least oneof the following: mailing address, phone number, or e-mail address. The information in this box will be given out to the public in case they Call about your show. The producer name may be real fictitious, but thecontact information must be legitimate.
 
First Name
 Last Name
Organization Name
Mailing Address
Home Number (415) 555-5555
 Business Number (415) 555-5555
 
Email Address
  
 
Series only: You may designate one person in addition to yourself to pick-up and drop-off your tapes for this show in case you are unable to do so.
First Name
 Last Name
 
All Access San Francisco producers must be San Francisco residents aged 18 or over. As proof of you ridentity and age, you must submit either a current California driver's license or California identification card. If your current San Francisco home address is not printed on your photo ID, you must provide some other printed proof of residency such as a utility bill, bank statement, or voter registration. Personal letters and documents with handwritten addresses are not acceptable. Whatever document(s) you submit will be photo copied and kept on file for internal use only.

Bysigning,I agreeto allof thefollowing:

  • All of the information I have provided on this application is truthful and accurate.
  • I am a resident of San Francisco, aged 18 or over.
  • It is my responsibility to update any information pertaining to me that may change in the future.
  • I am familia rwith and will abide by all Access San Francisco policies and procedures. I will also abide by any and all changes and/or additions there may be to these policies and procedures in the future.
Date
Completion of this section is entirely optional. Any answers you provide will be used for statistical purposes only.
 
 
Are you a cable TV subscriber  
 
How often do you watch public access?  


  How did you hear about public access?  



  Ethnic group