1.  Working title for your program: 

2.  Primary contact name: 

3.  Address:    City:     State: 

4.  Phone:    E-Mail: 

5.  Additional Co-Host Names and Phone #'s:

6.  TYPE of Show (Must check one)

Discussion (list general subject)

Music (list genre)

Information (news, weather, sports) 

Hybrid (talk & music, drama & music) 

Other (describe briefly 

7.  Please give a brief description of your show:

8.  Do you have prior experience on the air?  Yes  No  If yes, please describe:

9.  Length of your program (minimum of 1 hour...1 hour increments)  1 hour  2 hours  3 hours

10.  Is your show:  Developed  Roughed in  Still an idea  Not sure

11.  Do you have access to resource materials (music, props, etc):  Yes  No

12.  Please mark to the best of you ability, the days and times that you would be available to be on the air. 

Mark ALL times that apply. Mornings  Afternoons  Evenings  Nights

Mark ALL days that apply. Monday  Tuesday  Wednesday  Thursday  Friday  Saturday  Sunday