MEDIA

MEDIA REGISTRATION FORM

Name of Company: ________________________________________________

Company Website: ________________________________________________

Type of Company (TV, Magazine, Web, etc.) ___________________________

Name: ___________________________ E-Mail: _______________________

Phone ___________________________ Fax: __________________________

Mailing Address: __________________________________________________

What type of equipment will you be using?______________________________

Number of Passes Needed: _______________

Names of Staff Members: 1. ______________________ 2. __________________

3. ______________________ 4. __________________

By completing & signing this form, you agree to participate in the 2010 YGEA Awards Ceremony. You will be allocated 2 passes. Additional passes will be distributed at $15 p/pass. You accept that your reserved location will be set by the Media Coordinator and agree that your company will pick up media passes one week prior to event. You will be contacted on the whereabouts to pick up your passes. In the event that you are late for your set up, contact the coordinator for alternative arrangements.

You also agree that you will release footage of what you tape (audio & video) and/or write up in a magazine within two weeks after the event. We appreciate your cooperation and participation.

Authorized Printed Name: _______________________________________

Authorized Signature: ___________________________________________

Title: _____________________________ Date: _____________________

Please send in this form as soon as possible so you will be assigned a location. Deadline for Media Registration is September 15, 2009. Email form to: This e-mail address is being protected from spambots. You need JavaScript enabled to view it . Or mail to address below.

YGEA Awards

2462 Feathertree Lane, Suite A

Lawrenceville, GA 30044 

Attn: Media Registration