Falls Run Information Channel 20

Broadcast Request

Requestor’s Name:  ____________________________________ Date:  __________

Phone Number:  _________________

Email Address:  _________________________

(Note: Request must be submit 2 days before Start Date on the broadcast)

Information:  _____________________________________________________________________________

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 Single Broadcast            Multiple Broadcasts (specify all dates)

Start Date(s):  ______________ End Date(s):    ______________Time(s):  _____________

       ______________                                  ______________                    _____________

       ______________                                  ______________                    _____________

      ______________                                   ______________                    _____________

Approval:

_____________________________________________   _________________

Activities Director                                                                         Date