Williamsburg's Third International Surrealist Film Fest, October 13th & 14th, 2006

Official Submission Form ------------------------------

english language title ________________________________________

original language title _______________________________________

country(ies) of production ____________________________________

original language(s) __________________________________________

running time __________________________________________________

date completed ________________________________________________

original format _______________________________________________

aspect ratio: _ 1:33 _ 1:66 _ 1:85 _ 2:35 (scope)

optical sound format: _ mono _ Dolby A _ Dolby SR _ Dolby Digital _

other _______________________________________________

submission fee: _ $15

method of payment: _ check _ money order

principal contact information: name __________________________________________________

position with film or music video _____________________

address _______________________________________________

city ____________________ state ____ zip ____________

day phone _________________ eve phone ________________

fax ________________ e-mail __________________________

director: name __________________________________________________

address _______________________________________________

city ____________________ state ____ zip ____________

day phone _________________ eve phone ________________

fax ________________ e-mail __________________________

writer: name __________________________________________________

address _______________________________________________

city ____________________ state ____ zip ____________

day phone _________________ eve phone ________________

fax ________________ e-mail __________________________

producer: name __________________________________________________

address _______________________________________________

city ____________________ state ____ zip ____________

day phone _________________ eve phone ________________

fax ________________ e-mail __________________________

additional credits: camera ________________________________________________

editor ________________________________________________

principal cast ________________________________________ _______________________________________________________

artist (music video only) _____________________________

label (music video only) ______________________________

screening history: screenings in US and abroad (including festivals) _____ _______________________________________________________ _______________________________________________________

television presentations  ______________________________________________________ _______________________________________________________

prizes or awards ______________________________________ _______________________________________________________

representation (if applicable): world sales representative ____________________________

telephone ___________________ fax ____________________ email _________________________________________________

U.S. sales representative _____________________________ telephone ___________________ fax ____________________ email _________________________________________________

How did you hear about Williamsburg's Third International Surrealist Film Festival? _______________________________________________________

 _______________________________________________________

release:

I, the undersigned, acknowledge and agree as follows: 

I have read, understood and complied with all eligibility requirements.  To the best of my knowledge, all of the statements in this document are true.  This film is not subject to litigation and is not threatened by any litigations. 

I hold Williamsburg's International Surrealist Film Festival harmless from damage to or loss of the print en route to the Festival.

I am duly authorized to submit this film to the Festival.

signature:

date:

Send to

The Williamsburg Art and Historical Center

135 Broadway

Brooklyn, New York   11211

Attention:  Peter Dizozza

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