4th Annual PSA Contest Video Submission Form

4th Annual PSA Contest
“Change the World in 30 Seconds”
Submission Deadline:October 8th, 2008
Brought to you by your local community access centers.
Send Submissions to:
294 North Winooski Ave. Burlington, VT 05401
Contact: morourke [at] channel17 [dot] org 802-862-3966 x16
Entry form and PSA due August 15, 2007

I recognize that by submitting my entry it will be judged by a panel chosen by the Contest Partners. I allow that my PSA is not under copyright and that I have the ability to enter it into this contest. I represent and warrant to you that the entry is original, is my own work and if other persons were involved they agree to its being submitted here. I recognize that my entry will also become part of the Channel 17 archives and be shown on the air at any time. I will not hold Channel 17 or any other Contest Partners responsible for any results of my submitting this PSA to this contest.

Who made this Video?

Street, City, State and Zip please

give us a phone number to reach you at.

whn was the maker of this video born (are you in the youth category?)

Include a synopsis of your entry along with any special notes you would like to have included. List All video participants.

please note here your willingness to submit.

If you are using copywritten material and you have obtained permission please make a note here.

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