BATH COMMUNITY TELEVISION

4 Sheridan Road, Bath, ME. 04530

Phone 207-443-8387 Channel Time Application FAX 443-8361

Program Title_________________________________Length_______________

Producer_______________________________________________________

Tape Ownership Acess________Individual ________Organization__________

Underwriters: yes_____ no____ How Many (circle) 1 2 3 4 5 6

Organization (if applicable)_______________________________________

Address ____________________________________________________

Telephone _____________________ E-Mail Address_________________

REQUESTED PLAY DATES

Approved ______Denied______ Date _________________Time__________

Approved ______Denied______ Date _________________Time__________

Approved ______Denied______ Date _________________Time__________

Approved ______Denied______ Date _________________Time__________

I understand that the Bath Community Television Channel may offer additional playbacks of the above-titled program, and have secured all necessary performance and copyright releases. I agree to reimburse Bath Community Television, the city of Bath, and Susquehanna Communications for any copyright liabilitythat they may incur as a result of the cablecasting of the above-titled peogram. In addition I acknowledge that the above-titled program adheres to the guidelines of the program content as set forth in the Bath Community Television operations manual

Signature_____________________________ Date _____/______/______

Print Name __________________________________________________

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OFFICE USE ONLY

CTA CONTENT CB TONE SLATE TITLE PGM AUD2 CREDIT BLK CTRL

EVALUATION BY____________________________________________________

COMMENTS _______________________________________________________

BCTV 702 10/99