Community Program Request Form

Community Program 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.
File Name*
Program Title*
ex: (Audrey Wilsonʻs Cooking Show, Culture Corner, Etc.)
Episode #/Title*
Description of Program*
Program Length*

Hour Minutes
Video on Demand (NLTV COMMUNITY CREATOR ONLY)

YesNo
Does this Program contain Mature Content?*

YesNo
Category (Check One)*

Arts/EntertainmentCommunity Event/InfoCultural/EthnicEducationalFoodHealth/Well BeingReligious/SpiritualScience/TechnologySports
(FOR NLTV COMMUNITY CREATORS ONLY) TIME SENSITIVE:
Program must be aired within a specific time frame to be relevant. If yes, add dates below.
Start Date Date End Date Date
Name of Producer*

First NameLast Name
Signature *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
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)

This is for any signed permission letters and contact information for Copyright holder.
Cancelof
Today's Date

MonthDayYear
For record purposes
Should be Empty: