Media Registration Form (Page 2 of 2) in pdf

For Internal Use Only:

☐MS State _______________

2015 LITTLE LEAGUE BASEBALL

WORLD SERIES

☐Background Check Complete

☐Request approved

MEDIA REGISTRATION FORM

☐Recorded

L: ______ V: _______

☐Assignment:

Photo:_________

MEDIA INFORMATION.

PLEASE CHECK

ONLY ONE

OF THE FOUR CATEGORIES LISTED BELOW.

NOTE: MEDIA CAN ONLY RECEIVE A BADGE IN ONE OF THE FOUR CATEGORIES LISTED BELOW.

Please check all applicable boxes within your given category.

Television

Radio

Still Photography

Media

☐

Requesting parking for a

☐ Landline Requested

☐ Newspaper

☐

satellite vehicle on the complex

☐ Magazine

☐ Truck

☐ Online Publication/Blog

☐ Van

☐ Wire Service

☐ Landline Requested

☐ SUV

☐ Other ________________

ANTICIPATED ARRIVAL DATE 8/_____/2015

APPLICANT INFORMATION

Full Name: ___________________________________________________________________ Organization: ____________________________________________________________

First, Middle and Last

Social Security# (mandatory): _________________________________________________Date of Birth: ____________________________________________________________

Have you ever been convicted of; or plead guilty to; any crime(s): ☐ YES ☐ NO

Home Address: __________________________________________________________Business Address: _____________________________________________________________

City, State, Zip Code

Primary Phone Number: __________________________________________________Email Address: ________________________________________________________________

ASSIGNING SUPERVISOR INFORMATION

Name and Title (MUST BE DIFFERENT FROM THE APPLICANT NAME LISTED ABOVE):___________________________________________________________________________

Phone Number:__________________________________________________ Email Address:_______________________________________________________________________

Assigning Supervisor’s Signature:___________________________________________________________________________ Date:_______________________________________

Little League International World Series Media Guidelines Acknowledgement and Agreement

I _____________________________________________, of ______________________________________, hereby agree to all guidelines and procedures regarding the working

media attending the Little League Baseball World Series in Williamsport, Pa., as granted by Little League International, and as stated in the 2015 Little League Baseball

World Series Media Guide. I understand and agree that, following the completion of a required criminal background check, if credentials are issued to me, they are

property of Little League International. I understand that I, or any representative and/or associate of the aforementioned media outlet, am subject to immediate

revocation of World Series media credential(s) upon discovery of violations(s) of these guidelines. BY SIGNING THIS FORM I GRANT PERMISSION TO LITTLE LEAGUE

INTERNATIONAL TO PERFORM A CRIMINAL BACKGROUND CHECK:

Applicant Signature: ______________________________________________________________________ Date: _____________________________