Leominster Access Television Membership Application

Leominster Access Television
435 Lancaster Street, Suite 210
Leominster, MA 01453
978-537-7760
info@leominster.tv

LeominsterTV Membership Application

Statement of Compliance

I have read and am thoroughly familiar with the contents of the policies and regulations of Leominster Access Television.
I am thoroughly familiar with the content of the program materials to be taped, recorded and/or cablecast and state:

Neither lottery nor lottery material will be cablecast
No advertising material will be cablecast
No obscene or indecent material will be cablecast
Arrangements and/or clearances have been obtained from broadcast stations, networks, sponsors, music licensing organizations, performers or their representatives and any other persons necessary to authorize transmission of program material on this community access station.

I understand that I assume full responsibility for any dispute arising from unauthorized use of copyrighted material and agree to hold blameless in any disputes Leominster.tv, their employees and Board of Directors.
I understand I may be criminally or civilly liable for taping, performing and/or cablecasting any material which contains advertising, lottery or lottery information or obscene or indecent material.
I agree to pay cost of repairs to Leominster.tv equipment made necessary by abuse, theft, loss or careless handling while such equipment is in my possession (normal wear and tear excepted.)
False or misleading statements made in this application are grounds for forfeiture of the right to use Leominster.tv equipment and facilities.
I understand that all material produced using Leominster.tv equipment must be cablecast on one of the Leominster.tv channels.
I understand that if I profit in any way from material I produce using Leominster.tv equipment I will reimburse Leominster.tv in accordance with established Leominster.tv policies and procedures.
I understand that I must register with Leominster.tv a "Production Name", which will appear at the beginning or end of all productions I produce.
I understand that this is for an application, and I will not be considered a member until a staff member or Leominster.tv authorizes this application.
I hereby authorize Leominster.tv to use my likeness, both visual and auditory, for the purpose of promoting the station and its mission using various media unless I explicitly (in writing) inform LeominsterTV otherwise.
LTV members under the age of 18 years must be accompanied by a parent or guardian at all times when visiting or using the facilities of Leominster Access Television.

Applicant Personal Information

First Name: Last Name: Date of Birth:

Address: City: State: Zipcode:

Phone# email:

Payment Information

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and then enter your transaction ID in the box below!

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Do Not Enter Credit Card Number On This Form!

Applicant Signature

Date

By typing either your Initials or your Name,
you are signing your name! Please read before signing!

under 18...

Guardian Name:
Contact Info:
School:
Year of Graduation:

Organization Information

Organization:
Org Address:
Org City: Org State:
Org Zip: Org Phone:
Org Email:
Org Website:

Parent/Guardian Signature

Authorized Representative Signature

Having typed initials or names in the above designated boxes, I hereby acknowledge my signing of this application with all its
assumed privilages and responsibilities and understand that my membership may be terminated at any time with the full discretion of
Leominster Access Television