Enrollment is Now Open for the 2021-2022 School Year!Movie Licensing Request Form Thank you for your interest in Movie Licensing for your school or organization. BLaST IU17 is able to offer your district an exclusive discounted rate for a limited time annually until July 20, 2021, so act now to lock in your district for the 2021-22 academic year! Please fill out the following information about your school/district to see your discounted rate. Movie Licensing is based per building. Once you have finished and hit submit you will receive an email confirmation.A PURCHASE ORDER IS REQUIRED and will only be accepted AFTER JUNE 30th. Once we receive a PO, the license cannot be withdrawn and refunds will not be granted. Please submit PO's to Renee Peluso at rpeluso@iu17.org Account Status * Renewal License New License School District * Building Name * Student Enrollment 150 and Under - $334 151 - 300 - $384 301 - 500 - $408 501 - 1000 - $435 1001 - 1500 - $455 1501 - 2000 - $488 2001 - 2500 - $503 2501 - 3000 - $528 3001 - 3500 - $552 3501 and above - $576 Building Address (To Send License Certificate) * Building Address (To Send License Certificate) Street Address Street Address Additional Address Details Additional Address Details City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/PostalBilling Address Check if School Building and Billing Address Are Separate District/Business Office * District/Business Office Attention To: Attention To: Street Address Street Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Purchase Order Number * Contact Name * Contact Title Email Address * Phone Number * Questions or Comments The license effective dates will be 7/1/21 – 6/30/22. The invoice and official Movie License Certificate will be mailed at the conclusion of the enrollment period to the school and the address provided in this form. All payments will be made to BLaST IU17. Should you have any questions please contact Renee Peluso at rpeluso@iu17.org or call 570-323-8561 x1050. If you are human, leave this field blank. Submit