Public Performance of Video

Permission Request Form

Name of Organization: *
Address: *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone: * - (###) - ### ####
Fax: - (###) - ### ####
Email: *
Video Title Requested For Use: *
Description of Requested Use: *
Day of Use: * / MM / DD YYYY
Venue of Use:
Number and Description of Audience/Participants/Spectators: *
Do you plan to charge an admission or other type of fee? * No Yes
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Enter your initials here acknowledging you have read the above terms and conditions: *
Enter your initials here to warrant that you are an authorized representative of the organization named above, and you agree to comply with the terms & conditions noted above. *
Your Name: * Title First Last Suffix
Position: *
Today's Date: * / MM / DD YYYY
Would you like to receive news/offers from Big Idea? (Your information will not be shared with any 3rd Party.) * Yes No
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