Billerica Access Television, Inc.
Downloadable Community Bulletin Board (CBB) Request

NAME: _________________________________________ PHONE: __________________
ADDRESS: ________________________________________________________________
MAILING ADDRESS: _______________________________________________________
ORGANIZATION (if applicable): _______________________________________________
AUTHORIZED OFFICER (if applicable): ________________________________________
DATE TO BEGIN CABLECAST: ___/___/___ DATE TO END: ___/___/___

SIGNATURE: __________________________________________ DATE: ___/___/___

Please return to: Community Bulletin Board              or FAX to:
                  Billerica Access Television, Inc.     (978) 667-4969
                  430 Boston Road
                  Billerica, MA  01821



Staff Use:
Accepted _____ Rejected _____ Date: ___/___/___ Staff Initials: _____ Page#: _____
Reason(s): ________________________________________________________________

A

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