Community PSA Request Form

Community PSA Request Form
Submitting as a*

NLTV Community CreatorHawaiʻi Island Presenter
NLTV Community Creator: are clients certified with Nā Leo TV to use NLTV equipment, studios, or edit bays and are Hawai‘i Island residents.
Hawaiʻi Island Presentors: are clients who submit programs completely created with outside resources.
Date Submitted*

MonthDayYear
PSA Title*
PSA Length*

1:00 minute2:00 minutes
Does this PSA contain Mature Content?*

YesNo
Description of PSA*
(For NLTV COMMUNITY CREATOR USE ONLY)
TIME SENSITIVE: PSA must be aired within a specific time frame. If yes, add dates below. Start Date Date End Date Date
Name of Producer*

First NameLast Name
Signature*

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Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Today's Date

MonthDayYear
For record purposes
If you are NOT the Copyright Holder, attach a permission letter with a signature and contact information below. Please inform NLTV Staff when your contact information has changed. For more information regarding submission requirements or to review a copy of the Public Access Policies & Procedures click here or visit our website naleo.tv and look under resources.
Attach a File (not required)

Cancelof
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