NAME:
COMPANY NAME:
MAILING ADDRESS:
CITY:	PROVINCE: Select AB BC MB NB NL NS NT NU ON PE QC SK YT USA INT    POSTAL CODE:
BUSINESS PHONE:	BUSINESS FAX:
EMAIL ADDRESS:	CONFIRM EMAIL:
MEMBERSHIP ID#:

I am available to sit on a jury in June/July	I am available weekdays
I am available evenings after 5 p.m.	Weekend days preferable
If you work independently (not employed by a broadcaster) and are willing to serve as a jury chairperson, please check

To determine which category you would be most suited to as a juror, and to avoid conflicts of interest in the adjudication process, an indication of your primary experience will assist us in properly assigning you. Please indicate your MOST RECENT production experience:

Production Title:	Year:	Credit:
Production Title:	Year:	Credit:
Production Title:	Year:	Credit:

Drama	Comedy	Documentary	Animation	Children's/Youth
News	Sports	Variety	Performing Arts	Reality/Informational

Administrative Support	Agent	Animation/Visual Effects
Art Department	Broadcaster/Exhibitor	Broadcast Journalist
Casting Director	Cinematography	Creative Support
Director	Distribution/Program Sales	Editor
Executive	Music	Performer
Producer	Public Relations	Screenwriter
Sound