2016 ACADEMIC MEMBERSHIP FORM

MEMBERSHIP TYPE AMOUNT DUE Mr. Ms. Academic $49.00* Name:

*Must be a full time faculty staff or student. Title: Faculty: must provide current staff ID or other form of teaching verification at a college, university or high school. Student: Must proovide current student ID card and full time class schedule (minumum of 9 units). Organization: Address:

PROMAXBDA: THE CONFERENCE 2016 City: State: June 14-16, New York Hilton Midtown Zip Code: Academic Registration $99.00 Phone: Fax: Email: Website:

PLEASE CHECK THE APPROPRIATE BOXES IN THE 4 AREAS BELOW TO PROVIDE INFORMATION ABOUT YOU AND YOUR COMPANY CHECK ONE ONLY 1 CHANNELS (NBC, MTV, FOX, Canal+, MSOS/MVPDS (Comcast, Time ACADEMIC 3 JOB LEVEL BBC, A+E, etc) Warner, Star, DIRECTV, Virgin Media, etc.) Educator Executive Management (CMO, Cable Channel (MTV, Discovery, Bravo, Cable (Comcast, Time Warner, Virgin EVP, SVP, Managing Director, etc.) Student Disney Channel, etc.) Media, ONO, etc.) Senior Management (VP, Executive Broadcast/Terrestrial Network (NBC, ZDF, Satellite (DIRECTV, DISH, SKY, etc.) 2 DEPARTMENT/AREA Producer, etc.) CBS, BBC, DR, etc.) OF BUSINESS Game/Entertainment Console (Xbox, Director Pay TV/Subscription Channel (HBO, Playstation, etc) Marketing Mid-Level (producer, manager, etc.) Eurosport, LAPTV, Showtime, etc.) Internet (Hulu, iTunes, Youtube, etc.) On-Air Promotion Entry Level (assistant, coordinator, etc.) Satellite Channel (Audience Network, Mobile (AT&T, Orange, Verizon, etc.) Creative Services ARTE, DW-TV, etc.) Programming 4 JOB DESCRIPTION Internet Channel (Pitchfork, Machinima, SERVICE VENDORS/ Crackle, etc.) AGENCIES/CONSULTANTS Design Marketing Promotion LOCAL/REGIONAL BROADCAST Design/Motion Graphics/Animation Distribution Affiliate Marketing TELEVISION (KXLY, NY-1, WPIX, KCET, Creative Services/Advertising Agency Network Affiliate Marketing Design Comcast Sports Net, etc.) Production – Live Action Research Sales Local Station (KOMO, KCAL, WNBC, Post Production/VFX/Editing Services Interactive/On-Line Programming & Production etc.) Public Relations Affiliation #1 Internet/Interactive Services (creative, Media Planning technical, etc.) Integrated Marketing Affiliation #2 PR Legal Services Affiliation #3 Production Technical Media/Strategy Agency Ownership/Station Group Post Production Research Music & Sound: Licensing, Library, Creative Services Education/Training Call Letters Composition Legal Strategy Regional Channel/Network (NY-1, Fox Research Company Ad Sales Finance Sports Networks, CTV Toronto, etc.) PR Agency Business Development/Sales Other: Station Groups (Gannett, Tribune, Recruitment Agency Sinclair, LIN, etc.) HR/Recruitment Voiceover Other/Independent CONTENT PRODUCERS, Premiums/Incentives Provider PROGRAM DEVELOPERS, SYNDICATORS, DISTRIBUTION Event Production/Special Events (Warner Bros. Television, Endemol, Sony Technology Provider Television, Shine, etc) Talent Agency Studio /Program Production (Shine, Independent Consultant/Freelance Endemol, Lionsgate, etc.) Syndicator/Distributor (Warner Bros OTHER Television, Debmar Mercury, Sony Television, etc.) Trade Association or Conference Home Entertainment (Walt Disney Publications (trade, industry, consumer) Studios, 20th Century Fox, BBC Home Entertainment, etc)

METHOD OF PAYMENT Payment must accompany this invoice; please do not email/mail separately. Membership Renewal Fee $ Visa Mastercard American Express

Total Amount $ Check # Exp Date (MM/YY) Security Code Credit Card # Signature Conference Registration Amount $

Please mail completed form along with payment to: Fax (credit card payments only): +1 310.788.7616 NOTE: PromaxBDA memberships are individual memberships and are not transferable or refundable. Memberships can be purchased on a year-round basis, but are based on the PromaxBDA calendar year and will expire December 31. Any questions or concerns should be directed 5700 Wilshire Blvd. Ste. 275 For additional information, please call Member Services at to Member Services. PromaxBDA membership dues are not deductible as a charitable +1 310.789.1509 or email [email protected] contribution for Federal or National tax purposes. However, they may be tax deductible as Los Angeles, CA 90036 ordinary and necessary business expenses. Usually 100% of your dues are tax deductible, USA or visit our website at promaxbda.org. because PromaxBDA does not participate in any lobbying activities on behalf of its members. Always consult your advisor regarding these matters.