2002/2003 OFFICIAL EMMY AWARDS ENTRY FORM
(For entries telecast between June 1, 2002 and May 31, 2003)
UPPER MIDWEST CHAPTER
(Please type or print with care)

[ ]  ENGLISH LANGUAGE	[ ] FOREIGN LANGUAGE

CATEGORY NUMBER:		CATEGORY TITLE:

ENTRY TITLE:
(Please list title of program or entry as you would want it to appear on the ballot, and in the program book.  Also, make sure the title on this form matches the title on the tape label.)

AIR DATE:				LENGTH OF ENTRY:

STATION THAT AIRED ENTRY:

TAPE TIME CODE:
(Best 30 seconds; see Call for Entries, page 7, for information)

PRINCIPALS ELIGIBLE FOR AWARD AS LISTED IN THE CALL FOR ENTRIES:
Please list position (reporter, producer, etc.) next to name and list name as it should appear in the program book.  Do NOT list anyone who is not eligible for a statuette.  In the event this entry is awarded an Emmy, the Entrant listed below will receive the statuette.  Check to make sure all names and titles are correct and complete.  A reprocessing fee of $25 will be charged for each changed made after the entry is submitted.

ENTRANT NAME/POSITION:
(This is the first person listed as eligible for an award who receives the statuette)

2.

3.

4.

5.

6.

AMOUNT PAID FOR THIS ENTRY:  $
(See Call for Entries for fee information)
   Company Check		   Personal Check		   Credit Card		   Purchase Order
When a SINGLE CHECK covers MULTIPLE ENTRIES, a list of all entries covered MUST accompany the check.

CONTACT NAME:
PHONE:
EMAIL:
COMPANY/STATION:
ADDRESS:
CITY:						STATE:			ZIP:

IMPORTANT:
I represent and warrant that no entry submitted herewith is being challenged or contested as to its accuracy, whether it is a legal proceeding or by a tribunal whose function is to determine such issues.  I will report to the chapter or keep it appraised of such challenges or contests.  I understand that the chapter may, in its discretion, delay, refuse, withdraw and/or revoke an award given to any Emmy entry which, in its sole judgment, is determined to be inaccurate or questionable as to accuracy.

The success of the Emmy Awards program depends upon willingness of quality television professionals to act as judges.  Because peers in another market are serving this chapter's entrants, EVERY ENTRANT will be expected to judge another market's entries.  I understand that I will be expected to judge another market's entries.

CONTACT/ENTRANT'S SIGNATURE:

DATE:

You may include descriptive material.  Please limit to a single sheet of paper and attach to all copies of form.

THIS FORM MUST BE SUPPLIED IN DUPLICATE.  A THIRD COPY OF FORM MUST BE PLACED IN THE TAPE BOX.

WARNING:  Entries that are missing information on the form, have incorrect fees and/or do not follow the guidelines listed under EMMY Tape Preparation will be subject to a $25 reprocessing fee for each correction, including the addition or deletion of names.  In the event of disqualification from the Upper Midwest Regional Emmy Awards, the original entry fee will not be returned.