City, State, Zip_________________________________________________________________
Title of DVD (s) _____________________________________________
Contact info to be included on DVD ( website? 800 number?)
___ My DVD already includes that information at end
___ Please add this information on the end
I certify that I am the copyright holder or agent of copyright holder of the above listed DVD(s). I give my permission for Pickleberry Pie Inc. and the GetWellNetwork to use a copy of portions of the DVD (s) without charge for educational purposes in hospitals. This would be for a period of one year at each participating hospital from the commencement of a hospital's use of the content from the listed DVDs, with the possibility of renewal. I will be notified by email if my work is selected for participation.
SEND one copy of each DVD TO:
Pickleberry DVD Review Committee
210 Ross Dr. SW
Vienna VA 22180
Send without requirement of signature Thank you!!