Cablecast Agreement

Program Title:*

Airdate:*

Date

Producer Name:*

First NameLast Name

File Name:*

(ShowName_Month_Date)

Episode:*

New (or has not aired in past year)Repeat

Program Length/Timeslot:*

29:0059:00

This program contains material of a mature nature and may not be suitable for young viewers (must be aired between 11 PM and 6 AM):*

YesNo

Include this program as part of:

CMPAC Rewind (second airing to fill schedule gaps)*

Video On Demand (available on Access 21 website for approx. 6 weeks after airing)*

This agreement is between Charlotte Mecklenburg Public Access Corporation and the Producer named on this form, to cablecast the attached program on a Public Access Channel.

I, the Producer of this program, by signing this form, do hereby indemnify and save harmless, The Charlotte Mecklenburg Public Access Corporation from any and all liability, loss, damage, expense, cause of action, suits, claims or judgments, including attorney fees arising out of, connected with, or resulting from the cablecasting of the above named and attached program.*

Yes

I, the sole owner of this program, do hereby grant permission to The Charlotte Mecklenburg Public Access Corporation to cablecast the above named and attached program. I have obtained all necessary written authorizations for use of any material contained in this program for which I do not hold the copyright, and have submitted copies of all authorizations.*

Yes

I, by signing this form, do hereby attest that all the information entered herein is true and correct, and that the program delivered will adhere to all rules and regulations in effect at the time of signing, and that the program is my personal creation except as noted above.*

Yes

Signature*

Submission Date:*

Date

Time*

Hour Minutes

AM/PM Option

Email (for submission notification)

example@example.com