Single Timeslot Request

First Name: *

Last Name: *

Residence Adress: *

(no P.O. boxes – you will be required to provide address verification)

Apt.: *

City: *

State: *

Home Phone: *

Work Phone: *

E-mail: *

Are you eighteen years of age or older?: *

Yes

(If under 18, a parent/guardian is required to sign the Program Agreement)

Have you ever ATTENDED A MNN ORIENTATION WORKSHOP?: *

Yes

Did you use MNN equipment to produce this project?: *

Yes

If yes, please include your PROJECT ID number given to you by the Production Department S-:

Public Information: *

Should viewers ask to contact you this information will be released to the public –include email, address and/or phone #

Program Title: *

(max. 20 Char. for cable guide)

Program Description/Narrative: *

(for publication-20 words or less)

Program Length: *

Half hour (show will receive three timeslots and should be no longer than 28 min.)

One-hour (show will receive two timeslots and should be no longer than 58 min.)

Longer than an hour (show will receive one timeslot, subject to availability.)

*Runtime does not include the required minute of pre-roll before the program or minute of end roll after program.

My three preferences for a time slot are

Day One: *

Time One: *

Day Two: *

Time Two: *

Day Three: *

Time Three: *

What format will submitted videotapes be?: *

DVCAM

Mini-DV

Live*

If your program is live will you be using an MNN studio?:

Yes

If you are not using a MNN studio and your program is live, where will program originate from?:

If yes, which studio do you intend to use?:

Are you certified or do you have certified crew for use of the studio?:

Yes

Please list any additional equipment or facilities you plan to use for this show only:

Are you certified or do you have certified crew for use of this equipment?:

Yes

This program is produced by: *

Another individual or organization

If other, please provide name & address of program’s producer: *

Does this program require a disclaimer under MNN’s Program Policies for adult, violent, or medically graphic programming?: *

Yes- schedule program after 11pm (please refer to the current Program Policies).

Does this program contain fifty percent or more of material produced by someone other than you (i.e. video clips, film/TV, etc)?: *

Yes

Do you currently have another program scheduled on Manhattan Neighborhood Network?: *

Yes

If yes, what program?:

Is this program currently cablecast in whole or in part on another channel in Manhattan?: *

Yes

If yes, what channel?:

Have you had another program scheduled within the last twelve months on MNN?: *

Yes

If yes, what other program?:

Is the program host regularly seen on another program on Manhattan Neighborhood Network?: *

Yes

If yes, what MNN program?:

Has the program host regularly hosted another program scheduled on MNN within the last twelve months?: *

Yes

If yes, what other MNN program?:

Date: *

Signature: *

This application will not be processed if:

- you did not sign this request form

- you did not fill this request form out completely

- you did not submit a program tape (videotape) with this request

- you did not sign the MNN Program Agreement & submit it with this form

	TWC	RCN	FiOS
1 Community Channel	34	82	33
2 Lifestyle Channel	56	83	34
3 Spirit Channel	57	84	35
4 Culture Channel	67	85	36