Carnegie/Notable Children's Videos Application/Submission Form

Title _______________________________________________________________________________

Running Time ______________ Copyright Date _______________ US Release Date ____________

Purchase Price ________________ Rental Price _____________________

Producer _____________________________ ____    US Citizen/Resident Yes___   No¬____

Street Address _______________________________________City____________________________

State _____ Zip __________   E-Mail Address _________________________     

Telephone _________________    FAX ___________________ 

Distributor __________________________________________________________________________

Contact Name _______________________________________________________________________

Street Address ___________________________________________ Telephone __________________

City _____________________________ State ______ Zip _________ FAX ______________________

E-Mail Address _________________________     Web site URL:
Has this title been previously released in another format?  No _____ If yes _____, explain

Is this title part of a series? No _____  Yes _____  Series Title __________________________________

Are public performance rights available for library programs?  No ______  Yes ______

Do you wish to have your video returned to you after the committee has evaluated it?

     No ____  Yes ____  If yes, please enclose postage and a mailing label.

Please send a copy of this form with each video to the Committee Chair and the ALSC Office.  In order that more than one member of the committee may view a video, please consider also sending videos with submission forms to the other committee members.  If you have any questions, please contact the committee chair:

 Caitlin Dixson Jacobson, Chair                    

Ketchikan High School Library    

2610 Fourth Avenue      

Ketchikan, AK 99901

ALSC Office
Attn: Carnegie Submission OR Attn: NCR Submission OR Attn: Carnegie/NCR Submission
50 East Huron Street
Chicago, IL 60611
Submission Deadline: December 31, 2014