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2. 
4. Program Title (max. of 25 characters)
5. Date
   Date
7. Program Description (max. of 200 characters)
11. Adult Content (check all that apply)

    1. Language/Profanity
    2. Nudity
    3. Sexual Content

    1. Depicts Violence
    2. Other
13. Is this program suitable for viewing by children?

    1. Yes
    2. No
17. Name of Program Creator
19. Program Creator Email Address
21. Program Creator Phone Number
25. Click to read Operational Rules
    OPERATIONAL USE POLICIES
27. I certify that I have read Burnsville Television’s OPERATIONAL USE POLICIES, and I understand that I am responsible for the content of the program that I produced for playback on the access channel(s). I affirm that:

    •No lottery information will be cablecast •No obscene/indecent material or language shall be cablecast, nor programs that promote illegal acts. •The program contains no advertising, soliciting for funds, or revenue generating activity. •All clearances have been obtained from performers/talent, stations, sponsors, copyright holders, etc. •If a live cablecast, I have taken reasonable measures to ensure compliance with this statement.

29. I assume full responsibility for any disputes arising from unauthorized use of copyrighted material. As producer, I am solely responsible for the content of this program series.
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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