Name

Panelist Name

Email Address

Panel or Program Name

Panel or Program Description

Is this a Mature Audiences Panel? Will attendees need to be 18 and provide a valid ID to attend? Is this a Mature Audiences Panel? Will attendees need to be 18 and provide a valid ID to attend? Yes No

Will you require visual equipment? (requesting visual equipment does not guarantee the availability) Will you require visual equipment? (requesting visual equipment does not guarantee the availability) Yes No

Panelist Topic Policy (I agree to the panelist promotion and topic policy as stated in the description above) Panelist Topic Policy (I agree to the panelist promotion and topic policy as stated in the description above) Yes No

I agree that I have read the above requirements: I agree that I have read the above requirements: Yes No

I agree that I have filled out this form to the best of my abilities I agree that I have filled out this form to the best of my abilities Yes No