Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Licensee Name (organization)
*
Term of License (YEARS)
Please Select
1
3
10
Scope of Screenings
Please Select
Internal members or students ONLY
May include individuals from outside our organization
Will the screenings ever include members, students or individuals that are considered EXTERNAL to the licensing organization?
Licensee Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
By: Paul Heinzelmann
Its: Owner
Signature ________________________________
Patsy Productions, LLC
signature
*
Name of Licensee Representative
*
Title or Role
*
Licensee Representative Email Address
example@example.com
Film format for your library
Please Select
MP4
DPC
Other
OTHER COMMENTS OR QUESTIONS?
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