First Name
Last Name
Email
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Organization Name
Address
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Interested Days MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Program Format LivePre-Recorded
Program Name
Length of Program (e.g. 30 minutes, 2 hours)
Type of Program SermonTalk ShowChildrenMusicFilmNewsOther
Has your program been aired on another network before? YesNo
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