Free 53847.pdf - Indiana

IDEM PUBLIC SERVICE ANNOUNCEMENT (PSA) CONTEST ENTRY
State Form 53847 (1-09)

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Indiana Department of Environmental Management INSTRUCTIONS: 1. Complete all lines of the entry form. 2. Sign and date the release section. 3. By submitting your entry you are indicating that you have read and agree to all contest rules. ENTRY INFORMATION
First and Last Name of Artist First and Last Name of Sponsoring College or University Contact Name of Sponsoring College or University Sponsoring College or University Contact E-mail Address

Address of Sponsoring College or University (number and street, city, state, and ZIP code) Phone Number of Sponsoring College or University Contact (with area code)

(

)
PSA Format and Size (Mb)

Title for Public Service Announcement (PSA)

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Artist's explanation of the intended key message being conveyed in the created work. (maximum of 100 words)

RELEASE SECTION I hereby give the Indiana Department of Environmental Management (IDEM) the right to use this PSA entry in any, advertising/promotional materials (print, electronic, etc.), and exhibit and display at all IDEM-hosted/sponsored events including but not limited to digital reproductions, with credit given to the artist. Entries may not be copyrighted. IDEM reserves the right to allow the use of the materials by third parties. I hold IDEM harmless from any and all liability that might arise out of or result from the foregoing use. Your entry signifies that you will abide by all rules, including that you will provide a true signature if your PSA is selected in the contest.
Signature of Sponsoring College or University Contact (RETAIN A COPY OF THIS FORM) SIGNATURE WILL BE REQUIRED IF YOUR ENTRY IS SELECTED Date (month, day, year)

College or University contact telephone number:

Printed Name

Are you at least 18 years of age?

Yes
Parent's Signature (if applicant is under the age of 18) Are you an Indiana resident?

No

Printed name of parent Are you a U.S. Citizen or permanent legal resident?

Yes

No
IDEM PSA Contest MC 50-03, IGCN 1313 100 North Senate Avenue Indianapolis, IN 46204-2251

Yes

No

Return Completed Entries to: By Mail MUST PUT THE IMAGE AND THE ENTRY FORM ON CD: By e-mail YOU MUST E-MAIL THE FORM AND THE IMAGE: Entries may be dropped off between 8:15 a.m. and 4:45 p.m. Monday through Friday at:

[email protected] Indiana Department of Environmental Management Indiana Government Center North 100 N. Senate Ave. Rm. N1313 Indianapolis, IN 46204

See reverse for rules.

General IDEM PSA Contest Rules
Contest is administered by the Indiana Department of Environmental Management (IDEM) to solicit public service announcements for promotional pieces that the agency does. Any photographic images must be of Indiana locations. PSA entries may not contain any type or words superimposed over the image in English or any other language. The PSA entry can be in the form of audio, video or both. PSA entry may be sent via postal service or e-mail. Contestants must not be employed by the Indiana Department of Environmental Management. PSA entry must be the original work of the contestant. PSA entry must be the sole work of the contestant(s). PSA entry allows IDEM to reproduce the work in any of its promotional pieces (electronic, print, etc.) and for use in promoting other contests for the agency. A completed entry includes the PSA and a completed PSA contest entry form, which are sent via postal service or emailed to IDEM at the following addresses: Postal Service: IDEM PSA Contest MC 50-03, IGCN 1313 100 North Senate Avenue Indianapolis, IN 46204-2251

E-mail: [email protected] with subject line "IDEM PSA Contest"