3C Media Solutions

Production Services Request Form

Applicant Information
An asterisk (*) indicates required information.

Name*:
Title*:
Department*:
College*:
If not college, Organization or Business Name:
Address*:
City*:
State*:
Zip*:
Phone Number and Extension*:
Fax:
Email Address*:
Applicant Background: (one page max)*	Please give a little background about yourself or organization and your interest.

Program Information

Program Title*:

Program Category * :

Program Style*:

Location*:

Type & number of talent*:

Type	Number
Voice Over
Lecturer
Host/Moderator
Actors
Guests

Proposed Program Length*:

Total number of episodes:

Why do you want to do this program?*:
(one page max)

Application Questions

*Program Content (30%):** (Describe your program clearly identifying and describing all elements ofthe program, including topic, subject matter, format style, target audience, length and production techniques)
*Need in the CCC system (35%):** (Describe the need for the program within the CCC system, and is there any source of information that can be provided?)
*Impact (15%):** (What is the intended impact of the program on the targeted audience?)
*Benefit (20%):** (What specific benefit will this program have on the CCC system?)

Program Synopsis

Outline of the program content or include script. Include a brief description of the episode or of individual episodes (one to five sentences each)*:

Program

Target Air Date*:
Kill Date:

Program Audience

Does your program have a system wide audience?*:	Yes No
If yes, please explain:
Describe the groups you're trying to reach with your programming.*:
What is the anticipated average viewership?*:

Estimated Budget
(A detailed budget will be included when the project is approved)

Salaries and wages:
Supplies and materials: (include all additional costs in this figure)
Equipment:
Total cost*:

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.