Organization Name
Contact First Name
Contact Last Name
Contact Email
Street Address
City
State
Zip Code
Federal Tax ID
Is your organization a non-profit or public tax-exempt organization? YesNo As defined under Section 501(c)(3) of the Internal Revenue Code
Desired Services Internet TV Both
Geographic Service Area
Please give a brief summary of your organization's mission
Number of residents your organization serves annually
Electronic Signature Please initial
Comments