Movie Licensing Request Form If you are human, leave this field blank. 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 1, 2018, so act now to lock in your district for the 2018-19 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. Account Status * Renewal License New License School District * Building Name * Student Enrollment 150 and Under - $314.40 151 - 300 - $362.40 301 - 500 - $385.20 501 - 1000 - $410.40 1001 - 1500 - $430.89 1501 - 2000 - $454.80 2001 - 2500 - $480.00 2501 - 3000 - $502.80 3001 - 3500 - $526.80 3501 and above - $550.80 Building Address * Building Address 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/Postal Contact Name * Contact Title Email Address * Phone Number * Questions or Comments The license effective dates will be 7/1/18 – 6/30/19. This registration is only to secure your school and/or district in the BLaST IU17 consortium discounted pricing for movie licensing. You do not need to send a PO for this. Once you submit your approval it will act as an official PO and you will receive an email confirmation. The invoice and official Movie License Certificate will be mailed in August 2018 to the school and address provided in this form. All payments will be made to BLaST IU17. Should you have any questions please contact Audra Mazzante at amazzante@iu17.org or call 570-323-8561 x1029. Submit
