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Program Weekly Series Bi-Weekly Series Monthly Series Special Promo/PSA Show/Series Title: Episode Title: Production Date: Requested Time Slots First Air Date: Last Air Date: Day Time : AM / PM Day Time : AM / PM Day Time : AM / PM Media Information Format: DVCAM Mini DV DVD SVHS Live Show From Lompoc Total Running Time (including disclaimer) : : (Please do not put frames) (hh) (mm)(ss) Timecode (DV submissions only) In-point : : Out-point : : (hh) (mm)(ss) (hh) (mm) (ss)

Program Type (please check one): Children Cultural Educational Entertainment Health Instructional Music Political Public Affairs Religious Sports Other: Has program previously aired on SMCTV? Yes No If “Yes”, please provide dates and times Was program/episode produced within SMCTV facilities? Yes No Has episode been previously submitted for cablecast on SMCTV? Yes No If “Yes”, please provide dates and times List all underwriters for this show: May SMCTV copy or excerpt this program for promotional purposes? Yes No May SMCTV provide copies of this program to third parties, i.e., guests appearing on the program? Yes No

We encourage you to STOP A MOMENT AND THINK. Your program will be cablecast to over 23,000 homes in the Santa Maria and Northern Santa Barbara County area, where there are children whose television viewing habits may or may not be closely supervised. Programming identified by producers as containing adult content and adult themes will only be shown between the hours of 12 midnight and 5am. In this section you have the opportunity to make a responsible decision to limit the time of day your program will be scheduled by answering the following questions: Does this program contain: Yes No Adult language: language which refers to sexual intercourse and/or sexual behavior in any form, sexual or excretory organs or activities, or depictions thereof? Yes No Extreme acts of violence against people or other living things? Graphic depictions of violent acts, images or sounds of violent human or animal mutilation, torture, or death? Yes No Depictions of , sexual content, or any other presentation that involves the depiction or simulation of sexual acts in any form? Yes No Hate speech: speech intended to degrade, intimidate, or incite violence or prejudicial action against someone based on his/her race, ethnicity, national origin, , sexual orientation, or disability? Yes No Illegal content: content that is not protected by the First Amendment to the United States Constitution, i.e., , slander, defamation, or unauthorized use of copyrighted material, etc.? I have permission to use any copyrighted material contained in the content of this program. This program does not contain commercial content as defined by SMCTV’s policies and procedures. Signature Date

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