Name
of artists__________________________________________________________________
Street address_________________________________________________________________
City, State, Zip_________________________________________________________________
Contact person_____________________________________________
Phone number_______________________________________________
Email address______________________________________________
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.
Signature_______________________________________________________
Print name______________________________________________________
Date______________________________________________________________
SEND one
copy of each DVD TO:
Irene
Light
Pickleberry DVD Review Committee
210 Ross Dr. SW
Vienna VA 22180
Send without requirement of signature