Application Form

EACH applicant should fill out an entry form. A complete application includes payment. Slots will NOT be held until payment is received.

Category (check one)

[  ] Individual $700 / $850 (After January 1st, 2008)

[  ] Team $1400 / $1700 (After January 1st, 2008)

[  ] $100 Team Discount if at least one of the team is an NPPA member

Note: Registration money will not be refunded for teams that cancel after March 21, 2008.

Registration Data

Name___________________________________________________________

Home Address___________________________________________________

City________________________ State______ ZIP___________________

Country________________________________________________________

Email Address__________________________________________________

Home Phone_____________________    Work Phone__________________

Station _________ Position_____________________________________

Name of partner________________________________________________

Graduate of News Video Workshop? [  ] Yes [  ] No

Years experience in journalism__________

NPPA Membership Number____________

Equipment Format:

Camera____________________________

Editing___________________________

T Shirt Size [  ] Medium [  ] Large [  ] Extra Large

Payment

Amount due $__________ Check enclosed #__________________

Credit Card_________________________________________________

Exp. date__________________ Verification Number_____________

Name of Card Holder (please print)__________________________

Cardholder Address__________________________________________

City______________________ State ________ ZIP ______________

Signature___________________________________________________

Send Registration Form to

Advanced Team StoryTelling Workshop
Pat Holloway
10904 E 28th Terr
Independence MO 64052

Or fax credit card info to: 816-254-8649