Optimum

Cablevision of:

Applicant Name:

Date / Time Requested:	From: To:

Producer Name:

Director Name:

Technical Director Name:

Audio:

Graphics:

1st Camera Name:

2nd Camera Name:

3rd Camera Name:

1st Production Assistant Name:

2nd Production Assistant Name:

Are crew members trained and Qualified Facility Users?	Yes No

I have read the Cablevision Access Rules and understand that this application must be submitted at least thirty (30) days prior to the requested date on this application. I also understand that a completed Access User Contract must be submitted at least fifteen (15) days prior to requested location date.
Applicant's Signature: ________________________________________ Date: ____________
Access Department Approval: ___________________________________ Date: ____________
Access Department Head Approval: ___________________________________ Date: ____________

Please fill out the above form, then click below to print it. Sign and date the form and mail or fax it to your regional access programming office.