SWANK MOTION PICTURES EXHIBITION REQUEST FORM	Page 1 of 1

CONTACT INFORMATION Organization Name: Click here to enter text. Contact Name: Click here to enter text. Phone Number: Click here to enter text. Secondary Phone Number: Click here to enter text. Email Address: Click here to enter text. How did you hear about Swank? Choose an item.
Mailing/Billing Address	Shipping Address (if different from billing)
Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.	Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.
Payment Information	Additional Event Details
Please select your preferred method of payment: ☐Check ☐Credit Card (it is optional to include credit card info below) Name as it appears on the card: Click here to enter text. Card Number: Click here to enter text. Exp. Date: Click here to enter text. Credit card billing zip code: Click here to enter text. ☐one-time charge ☐save card on file for future orders Are you PO required? Are you tax exempt?* ☐Yes ☐No ☐Yes ☐No	Are you charging admission or suggesting a donation for the event? ☐Yes ☐No If so, how much? Click here to enter text. Anticipated crowd size: Choose an item. Reason for the screening: Choose an item.

REQUESTED MOVIES

Movie Title	Date of Screening	Do you need Swank to provide the content for an additional $28 round trip shipping and handling fee?	Is your screening indoors or outdoors?	Name & Address of Screening Location
Click here to enter text.	Click here to enter a date.	☐DVD ☐Blu-Ray ☐No	☐Indoor ☐Outdoor	Click here to enter text.
Click here to enter text.	Click here to enter a date.	☐DVD ☐Blu-Ray ☐No	☐Indoor ☐Outdoor	Click here to enter text.
Click here to enter text.	Click here to enter a date.	☐DVD ☐Blu-Ray ☐No	☐Indoor ☐Outdoor	Click here to enter text.

TERMS AND CONDITIONS

Please check the boxes to acknowledge that you have read and accept the terms

☐	Cancellations - Notification of a change or cancellation must be given at least 10 business days prior to your event. If an unforeseen circumstance (i.e. inclement weather, equipment malfunction, etc) prevents you from hosting your event you have up to one year in which to reschedule the same movie at no additional licensing fees. Notify your Account Executive the following business day so they can note the last minute cancellation on your account.
☐	Advertising - You are permitted to use the studio approved artwork provided by Swank Motion Pictures. Please note that these images may not be edited or altered and must include the copyright symbol and studio name. We encourage you to inform your organization’s members and patrons via on premise posters, emails and private mailings. Advertising through media such as radio, television or newspaper is prohibited. Promotions by means of a lighted sign, billboard or marquee that can reasonably be seen by the general public may not include the name of the movie. If this policy is violated or your screening becomes openly competitive with a commercial theater, your screening(s) maybe cancelled without notice.
☐	Moratoriums - It is understood that in rare instances it may be necessary for a Studio, in its sole discretion, to withdraw a movie from exhibition. In the event of a withdrawal you may substitute for an alternate title or cancel the event without obligation to Swank Motion Pictures.
☐	Admission Charges or Suggested Donations- If you are charging admission for the event, the total cost of the licensing will be quoted rate versus 50% of your ticket sales whichever is greater. You must submit an audience report, including number of tickets sold, ticket price and total box office within 48 hours of your event.
☐	Payment – In most cases payment is due upon receipt of the invoice. However, if you are a new customer prepayment is required on your first three orders and payment must be received in order to validate licensing. *If you are tax exempt please provide a copy of your state tax exemption certificate.

Authorized Signature ________________________________________________________ Printed Name:Click here to enter text. Date: Click here to enter a date.

Complete and return to your Account Executive Click here to enter text. Via fax: 314-909-0879 or email: Click here to enter text.