2003 Production Certificate Order Form

If you qualify for a Production Certificate for contributing to your local Emmy Award winning program(s) or craft area, or know of someone who does, you may order one by filling out this form, which can be duplicated.

Certificates are $10.00 each for orders received before Friday, July 23, 2004.

After that date, they will cost $15.00 each. Please allow 1-2 weeks for delivery
after the deadline date of July 23rd.

Please type or print clearly:

(1) Name of Individual _______________________________________________________

(2) On-Air Credit for Individual_________________________________________________

(3) Entry Title of Program/Series _______________________________________________

(4) Title of Category_________________________________________________________

(5) Station or Affiliation_______________________________________________________

Enclosed is a check for $___________to cover the cost of _______ Production Certificate(s).

Send this form and your check, payable to NTA-NCCB Chapter, to:

NTA-NCCB Chapter
9405 Russell Road
Silver Spring, MD 20910

Please mail my Certificate(s) to:

Name ______________________________________________________

Address ____________________________________________________

City ______________________ State ______ Zip Code _____________

______________________________________ _____________________________

Signature Date

P.S. Engraved plates for your Emmy statuette(s) will be forthcoming (6-8 weeks).

P.P.S. For those extra special people, beautiful wood plaques with a Presidential-size Emmy figurine can be purchased for approximately $70.00 plus engraving and shipping charges. For more information, contact Dianne Bruno at 301-587-3993 or capitalemmys@aol.com.