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2. 
3. The Contra Costa County's Office of Communications and Media oversees public information and media relations. It is responsible for coordinating emergency communications countywide. The Office also serves as the Cable Franchise Administrator and operates five Public, Educational and Governmental (PEG) Access Channels, including Contra Costa Television (CCTV), that all broadcast 24/7.
4. 
6. Communication/Production requests
   Please fill out all fields below to the best of your knowledge. This information may be maintained as a matter of public record and may be used to update and inform you of channel policy changes and/or schedule conflicts with video services. If you prefer to mail in your contact information please print out the form below and mail it to:
8. Type of Services**

   1. Live Event Coverage
   2. In House/Studio Production
   3. Producing
   4. Editing
   5. For Air
   6. ESS-Footage Transfer and Cleanup

   1. Press Releases
   2. Scripting/Writing
   3. Translation
   4. Website Troubleshoot
   5. Permissions
   6. Consultation for Web design

   1. Photography
   2. Graphics
   3. Media Relations Consultation
   4. Marketing/Branding
   5. Emergency Support

   Please Select All that Apply
10. Contact Information *
    Government Agency:
11. Billing information
    (org number or billing contact name and address)
12. Urgent
14. Address:
15. City:
16. State:
17. Zip:
19. Phone Number:*
20. Email Address:*
22. Title of service requested*
23. Service date
24. Service time
26. Service Description
    (150 character limit):*
27. Service location
29. For Video Production requests:
31. Program Length:*
    For Video Productions requests.
32. Tape or disk needed
34. Preferred Dates and Times*
    Preferred Dates and Times

    Preferred Dates and Times
35. Second Choice
    Second Choice

    Second Choice
37. Playback Schedule*
    -- Select One --WeeklyMonthlyOther
38. Please explain if Schedule requested is "Other"
40. Although we make every effort to uphold your preferred schedule request, we cannot guarantee that your playback times will not vary.
42. Producer:*
44. Expiration Date:*
46. Additional comments for service requested.
47. 
    
49. Applicant hereby applies to Office of Communications and Media/CCTV for use of the Governmental/ Educational channel, website and Public Information material on the following terms and conditions:
51. 1. Applicant is submitting with this application a prerecorded program which Applicant desires to have cablecast.
53. 
    
55. 2. Applicant represents that (s)he has read CCTV Operating Policy and Procedures, and hereby agrees to abide by the terms and conditions contained therein.
57. 
    
59. 3. Applicant represents that (s)he is aware of the restrictions on "Program Content" set forth in Section D of the CCTV Operating Policy and Procedures and represents that the program does not violate any of those restrictions.
61. 
    
63. 4. Applicant represents that (s)he has made all appropriate arrangements with, and has obtained, without limitation, all necessary licenses and/or clearances from broadcast stations, sponsors, music licensing organizations, performers' representatives, copyright holders and any and all other persons (natural or otherwise) as are necessary to lawfully transmit program material over CCTV's Channel.
65. 
    
67. 5. If the cablecast contains copyrighted material, attach title of copyrighted works, names of authors and/or composers and documentation showing clearance from the copyrighted owner and/or licensing agent.
69. Copyright Clearance Documents
73. 
    
75. 6. Applicant hereby agrees to hold Office of Communications and Media/CCTV harmless from any and all loss, liability, damage or other injury (including the reasonable costs of litigation or the defense of any claim) CCTV may suffer as a result of claims, demands, costs or judgment against CCTV arising out of or in connection with Applicant's use of CCTV's channel, including, but not limited to, the failure to comply with any applicable local, state or federal laws, rules, regulations or other requirements; and claim for libel, slander or the invasion of privacy; any claim of infringement of common law or statutory copyright; any claim for the unauthorized use of any trademark, trade name or service mark; any claim for breach of contractual or other obligations owing to third parties by CCTV and for any other claim.

    Please sign.

    1. CCTV@contracostatv.org
77. 
    
79. 7. Applicant hereby waives any claim or right against Office of Communications and Media/CCTV resulting from the loss, destruction or damage to any videotape, dvd, or other media submitted by Applicant or resulting from the failure or refusal to cablecast the video media or cablecast it at the scheduled time. Further, Applicant hereby releases CCTV from all such claims. Applicant hereby represents that the video media submitted by him has no economic value other than the value assigned the videotape, dvd, or other media on which any information is recorded.*

    Please sign.

    1. CCTV@contracostatv.org
81. 
    
83. 8. Further, Applicant understands that its NAME and MAILING ADDRESS WILL BE MAINTAINED at CCTV's offices and may be made available to members of the public, including governmental agencies, upon reasonable request therefore. Applicant hereby consents to the release by CCTV of Applicant's name and mailing address to any members of the public, including any governmental agency.
Leave This Blank:


85. 1. Receive an email copy of this form.
86. Email address

    This field is not part of the form submission.

87. Submit

* indicates a required field