BKAT TV Playback Request Form

2. 

4. First Name

5. Last Name

6. Your Phone Number

8. Your Email for Playback Notification

9. Public Contact Information

   (Where people can get more information about this program)

11. Who You Are Representing

    1. Self
    2. Non-Profit

    1. Government
    2. Educational Organization

12. Name of Organization

14. Program Information

16. Title

18. Exact Length of Program

20. Hours

21. Minutes

22. Seconds

24. Source

    1. Local Program
    2. Imported Program

25. Format

    1. DVD *Note* DVD must have been recorded on DVD-R
    2. VHS or SVHS tape *Note* Tape must have been recorded in SP Mode

27. Potentially Offensive Material

    1. Check this box if this program contains any potentially offensive material (nudity, excessive swearing, and/or excessive violence). If checked, this program will ONLY air after midnight.

29. Agreement
    I certify that the information on this form is true. I agree to abide by the provisions of BKAT policies and procedures including those set forth in the current Policy Handbook. I have secured, or am able to secure, written permission for cablecast rights of all copyrighted material contained in this program(s). I assume full responsibility for any disputes or community controversy. I agree to work to resolve those disputes and hold harmless Bremerton Kitsap Access Television and any of its funding entities, both individual and organizational, for any damages that I may incur from the cablecast of this program. I understand that potentially offensive material will air after midnight. I understand this tape will air no more than 4 times in one 6-month season. I agree to pick up tape/DVD within three months of final playback or program will be discarded. I agree that BKAT reserves the right to release information about this document.

    I certify that the information on this form is true. I agree to abide by the provisions of BKAT policies and procedures including those set forth in the current Policy Handbook. I have secured, or am able to secure, written permission for cablecast rights of all copyrighted material contained in this program(s). I assume full responsibility for any disputes or community controversy. I agree to work to resolve those disputes and hold harmless Bremerton Kitsap Access Television and any of its funding entities, both individual and organizational, for any damages that I may incur from the cablecast of this program. I understand that potentially offensive material will air after midnight. I understand this tape will air no more than 4 times in one 6-month season. I agree to pick up tape/DVD within three months of final playback or program will be discarded. I agree that BKAT reserves the right to release information about this document.

31. Electronic Signature*

    By clicking the below "Submit" button, I am signing this application electronically.

    1. Yes
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field