POLONIA MULTIMEDIA FESTIVAL

‘POLISH HOMELANDS 2006’

ENTRY FORM

Film/Programme/Website -Title

Original………………………………………………………………………………………….

Polish……………………………………………………………………………………………

Projection length.........................................................................................................................

Author’s full name……………………………………………..………………..

Address:

Street…………………………………………………………………………………………….

Zip code…………………….. City…………………………… Country………………………

Phone………………………… E-mail …………………………. Website ……………………

Producer/Distributor name……………………………………………………………...

Address:

Street…………………………………………………………………………………………….

Zip code…………………….. City…………………………… Country………………………

Phone………………………… E-mail …………………………. Website ……………………

Detailed film/programme/website detailed information

1.Category

- documentary

- feature

- television programme

- radio programme

- multimedia programme

- website

2.Format

- DVD

- VCD

- CD ROM

-Betacam – if you agree to emit it on TV

- other…………………………………………………………………………………………...

3. Date and place of the first show/ first emission and awards.

……………………………………………………………………………………………………………………………………………………………………………………………………

4. Short synopsis ( not more than 60 words )

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...

5. Author and his/her achievements

Script:………………………………………………………………………………………….

Photography……………………………………………………………………………………

Montage…………………………………………………………………………………………

6.By submitting my work I understand that it may potentially be broadcasted on television or radio and I give my permission to this.

YES ( on condition )………………………………………………………………………

NO

7. By submitting my work I understand that it will be shown in Poland and I give my permission to this.

YES ( on condition )……………………………………………………………………………

Date……………………………Author’s signature………………………….

APPENDIX 1

Author Declaration

I certify that I am the Author ( entitled team member ) of work, titled

……………………………………………………………………………………. ,

submitted to International Polonia Multimedia Festival ‘Polish Homelands 2006’. I declare that the regulations Festival are known to me and I accept them without any restrictions.

Date……………………………….…..……Signature……………………..……………………

Full name , address..............................................................................................................................

APPENDIX 2

Producer Declaration

I certify that I am the Producer of work, titled

……………………………………………………………………………………. ,

submitted to International Polonia Multimedia Festival ‘Polish Homelands 2006’. I declare that the regulations Festival are known to me and I accept them without any restrictions.

Date……………………………….…..……Signature……………………..……………………

Full name , address..............................................................................................................................