Program Provider Agreement Series or Program Title Program Runtime* Program (MP4 no larger than 5GB) provided via:* Physical (USB drive) [Due to the pandemic, we are not able to accept physical media) Remote (Dropbox, Google Drive or other service) Provider Name* First Last Producer Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Producer Phone Number*Organization Organization PhoneDoes this organization serve Johnson County? Yes No Local Sponsor Name First Last If producer is not located in Johnson County, Iowa, the producer must provide a name and contact information for a sponsor who does.Local Sponsor Email Local Sponsor PhoneI hereby attest that this program does not contain the following:* any material that solely promotes any commercial product, service, or lottery any unlawful use of copyrighted material any material that contains libel, slander, or defamation of character; or is an unlawful invasion of privacy any commercial solicitation or appeal for funds any material that violates state, or federal law relating to obscenity any material that violates local, state, or federal law any material that violates the guidelines set forth by the North Liberty Communications Advisory Commission Was this program locally produced?* Yes No
