Smithsonian Affiliate Screening Request Form
Please submit the form 8 weeks in advance of your screening dates.
Browse the latest titles here: http://bit.ly/2K0DCn3

For additional information, contact: Elizabeth Bugbee e: BugbeeE@si.edu t: 202-633-5304

CONTACT INFORMATION
Affiliate Organization *
Your answer
Address Line 1 *
Your answer
Address Line 2
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Affiliate Contact - Full Name *
Who should we address the license to?
Your answer
Email Address *
Your answer
Phone *
Your answer
Marketing Contact *
Please provide full name and email address
Your answer
SCREENING DETAILS
Program 1 *
Include show and episode name. Please list the exact title you're looking for. Browse http://bit.ly/2K0DCn3 to get the title name. LIST ONLY 1 TITLE BELOW
Your answer
Program 1 - Screening Date & Time *
Date and time when screening will begin.
Your answer
Program 1- Length of Usage *
Number of screenings of this show
Your answer
Program 1 - Requested Delivery Date *
Date by when you would like the show delivered to you. 1 week prior to screening is recommended to allow time for testing.
MM
/
DD
/
YYYY
Program 2
Optional. If you want to screen a second title, list it below. List only 1 title at a time.
Your answer
Program 2 - Screening Date & Time
Your answer
Program 2 - Length of Usage
Your answer
Program 2 - Requested Delivery Date
MM
/
DD
/
YYYY
Program 3
Optional
Your answer
Program 3 - Screening Date & Time
Your answer
Program 3 - Length of Usage
Your answer
Program 3 - Requested Delivery Date
MM
/
DD
/
YYYY
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