3C Media Solutions

Distribution Service Request Form

Customer Information

Name:
Email:
Phone:
Community College:
If not a CCC, Business Name:
Is your business 501c3 tax exempt?	Yes No
Address:
City:
State:
Zip:

Request Detail

Are there any viewer/participant fees associated with this programming? (fees can include, but are not limited to: student enrollment, participant, site or CEU fees).	Yes No
If Yes, please provide your Fee Schedule:	Please copy your schedule and paste it here.
Is this programming being provided as course material?	Yes No
Purpose of Request:	What are you hoping to achieve by distribution of this programming
Describe how the distribution of your programming will benefit the CCC system:
Number of CCC's impacted by your programming:
Distribution Type Requested:
Program Category:
If "Other", Type of Program, please indicate type:
How will 3C Media Solutions receive the programming:

Programming Detail

Do you currently possess the content you would like 3C Media Solutions to distribute:

Yes No

If "No", when do you expect to receive the programming:

Description of Programming Content:

Do you have copyright clearances to broadcast the program(s):

Yes No

Will the program be closed-captioned:

Yes No

Number of Episodes/Programs:

Please list the title, length and frequency of play for each episode program: (if you need more space, please use the "Other Information/Special Requests" space below)

Episode/Program Title	Length (specify form of measurement, i.e. hour/minute/second)	Specify Frequency by week or month

Distribution & Measurement Detail:

Requested Broadcast Start Date:
End Date:
You must include an end date in order for this Request to be considered complete. We will require measurement data, by the end date, for evaluation of the project's success. The maximum end date may not exceed four months from the Requested Broadcast Start Date.
Target CCC Audience:	Who or what groups at the CCCs will benefit from this program distribution
Target Audience Outside of the CCC System:	Who or what groups outside of the CCCs will benefit from this program distribution
How will you notify the targeted group(s) identified above about the programming:
When will the notification occur:
Is 3C Media Solutions the sole distributor of this programming?	Yes No
How will your target audience access the distributed programming:
Estimated Average Viewership per Program:
% of Audience Viewing by 3C Media Solutions Webcast:
% of Audience Viewing by 3C Media Solutions Broadcast:
How will you measure actual Audience Participation/Size:
How will you measure actual Audience Response/Satisfaction:
Within 30 days of the broadcast end date, you MUST provide 3C Media Solutions with Audience Partipation/Size and Audience Response/Satisfaction data which you have gathered and analyzed through methods identified above.

Value-Added Detail

Would you like web pages created for your event?	Yes No
Would you like a banner ad created for your event?	Yes No

Other Information/Special Requests:

We reserve the right to discontinue the pilot at any time should the actual results prove the distribution unsuccessful or if the programming does not meet 3C Media Solution's vision or mission.

PRIVACY

3C Media Solutions is funded by a grant from the Chancellor’s Office, California Community Colleges. 3C Media Solutions is the
delivery system for distance education, training and meeting collaboration, linking the 112 campuses of the California Community Colleges System.
© 2009 3C Media Solutions. All rights reserved.