WGME-TV Individual/Non-Profit Release Form

If the news report you wish to purchase is about any kind of crime, an auto accident or fatal accident, or involves a lawsuit of any kind, the news report is not available for sale and must be subpoenaed in order to obtain it.

PLEASE FILL OUT, SIGN, & RETURN WITH APPROPRIATE PAYMENT (Please add $2.00 shipping to your total).  WE ACCEPT VISA & MASTERCARD CREDIT CARDS, PERSONAL AND CORPORATE CHECKS OR MONEY ORDERS MADE PAYABLE TO "SMITH ATWOOD VIDEO SERVICES, INC." PLEASE DO NOT SEND CASH.

News stories are retained by Smith Atwood for 30 days from the date of broadcast. Stories over 30 days old will be charged an extra $15.75 per story.
If you are tax exempt or if this is for re-sale, please enclose a copy of the appropriate certificate.

VHS _________ $47.25 (includes $2.25 tax)
FORMAT DESIRED:
(check one)		 Email _________ $47.25 (includes $2.25 tax)
IMPORTANT:
For each additional story edited onto
the same tape, please add $21.
DVD _________ $47.25 (includes $2.25 tax)
Additional
Copies:
VHS
DVD
qty:______
qty:______
$15.75 (per copy)
$21.00 (per copy)
IMPORTANT:
PLEASE ADD $2.00 shipping
to your total order

Please give as much detail as possible         I am purchasing a copy of a news report RE:

__________________________________________________________________________________________

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which aired on Channel 13 on the ____AM / PM news on (date)_____/_____/_____.

I UNDERSTAND THAT I AM BEING PROVIDED THIS COPY FOR IN-HOUSE USE ONLY.  I AGREE THAT THE COPY WILL NOT BE RE-BROADCAST, COPIED, EDITED IN WHOLE OR IN PART NOR USED FOR ANY LITIGATION, MARKETING OR COMMERCIAL PURPOSES.

________________________________________________________________________________________________________
(signature of responsible party)                                   (print name)                    (date signed)

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(Email Address)                                                                                      (telephone number)

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(shipping address)                                                                                     (Billing address, if different from shipping address)    

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(credit card number)                 (exp. date)         (3 digit security code, found on the back)

Please return this form with payment to:  Smith Atwood Video Services Inc.,
257 Deering Ave., Portland, Maine 04103 / FAX: 207-772-6723