PLEASE MAKE SURE TO INCLUDE THE

FOLLOWING WITH YOUR APPLICATION:

_PROOF OF RESIDENCY
_PAYMENT (CHECK/MONEY ORDER)
_PHOTO IDENTIFICATION
_PROOF OF TAX EXEMPTION
ALTERNATIVE PAYMENT APPLICANTS ONLY
_PROOF OF LOW INCOME
MEMBERSHIP APPLICATION _PROOF OF AGE

Please print NEATLY & CLEARLY and fill out both sides of this form.

Name: Organization (if applicable):

Street Address: Apt or Suite #:
City: State: Zip Code:
Home Phone: Alternate Phone:
PRINT E-mail Address: Birth Date (if under 18):

Gender: _Female _Male Age Group: _ 18 and under _19-24 _25-34 _35-54 _55-74 _75+
Race/Ethnicity:
_ White/Non-Hispanic _ Black or African American _ Native American/Alaskan _ Asian or Pacific Islander
_ Haitian _ Cape Verdean _ Hispanic _ Other

MEMBERSHIP TYPES (please check only one category)

_ New Membership _ Renewal
 Individual Basic / $22 per year. For Boston residents to request cablecast of programs on or Community TV Channel
Comcast 23 and RCN 83.
 Individual Full / $66 per year. For Boston residents who want Timothy Smith Network Multimedia Lab computer
access, media production training, and access to BNN production facilities and equipment for producing programs to
be cablecast. Reduced fee available for qualified low-income, youth, and senior applicants. Information available on
request.
 Organizational Basic / $55 per year. For Boston-based non-profit organizations or Boston-based public institutions
that would like to cablecast programs on our News and Info Channel Comcast 9/ RCN 15, our Community TV
Channel Comcast 23/RCN 83, and submit listings to BNN’s Community Message Board.
 Organizational Full / $220 per year. For Boston-based non-profit organizations or Boston-based public agencies that
are interested in Timothy Smith Network Multimedia Lab access, video production training, access to BNN
equipment for producing programs to be cablecast, access to BNN’s Community Message Board, and BNNLive
productions. Membership cost includes access for up to four representative members. Note: BNNLive eligibility is
based on an organization having met certain criteria. Contact BNNLive Studio Manager at 617-708-3226 for details.

Membership Amount Due: $ (workshop fees not included)

PAYMENT INFO (we are unable to accept cash)

_Check or Money Order, payable to BNN. Check Number: _________
_Credit card payment in person or by phone (Visa, Master Card only)
Please note what class(es) you want to sign up for, or other follow-up requests:

For Office Use: App Received: Needs: Civi Updated:

Payment: Member#: Expire Date:

3025 Washington Street | Boston, MA 02119 | Tel 617-708-3200 | Fax 617-708-3210 | www.bnntv.org
As of: 2/15/11 You Can Only Get It Here!
Please read the following information about BNN membership and sign below to confirm your understanding and
acceptance of these conditions. Please visit our website at www.bnntv.org for other membership and workshop
information, or contact us at 617-708-3224 or membership@bnntv.org.

1. Memberships are valid for one year. Upon expiration, a member may opt to renew.
2. Membership and class fees are not refundable or transferable.
3. Individual membership is limited to Boston residents. New and renewing Individual applicants must
provide proof of Boston residency. The following types of documents are examples of acceptable
proof: utility bill, bank statement, credit card statement, copy of a lease, or letter from Social
Security. Documentation must show the applicant’s name and Boston home address, and must be
dated within the last two months (12 months for a lease).
4. Organizational applicants must be based in Boston and must furnish proof of non-profit status such as a
501(c)(3) or a tax exemption certificate.
5. Organizational applicants are responsible for ensuring their designated representatives understand and agree
with these conditions.
6. All Individual Full members and Organizational Full representatives must attend a New Member Orientation
before registering for training or using facilities. Workshop registration following each Orientation will be
on a first-come, first-served basis.
7. Depending on availability, there may be limitations on the number of classes that a member may register for
at one time, and on the number of organizational representatives that may sign up for any single class.
8. All membership and workshop fees must be paid before taking classes or using facilities.
9. Certification is given on completion of classes and/or with permission of the instructor. Different facilities
and equipment types require different certifications.
10. All members must agree to become familiar with, and abide by, all applicable rules, guidelines and
procedures governing use of BNN resources including facilities, equipment and channels. See BNN
Membership Policy for details.
11. There are sometimes special requirements for participation in classes and use of facilities by members under
18 years old. Written permission of a parent or guardian is required.

I understand and accept the above conditions of BNN membership:

Member Signature: Date

Name and title of Signer if on behalf of an Organization:
Parent or Guardian for members under 18:
Name:

Organizational Full applicants: please provide information for each of your designated representatives
Birthdate
Name Home Address Home Phone Email (if under
18)

Signature: Date

3025 Washington Street | Boston, MA 02119 | Tel 617-708-3200 | Fax 617-708-3210 | www.bnntv.org
As of: 2/15/11 You Can Only Get It Here!
 Alternative Payment Application
BNN’s membership and workshop fees support our ability to provide services to all Boston residents and non-profit
organizations. Fees are not intended to exclude participation by anyone with financial constraints that prohibit full
payment. We offer two alternatives to those with limited income. Eligibility verification required for fee reduction.
1. Deferred Payment Plan

Membership Workshops
The fee for Access Membership may be paid in two equal Workshop fees of $25 or more may be paid in two equal installments:
installments: • Half due at registration
• The first payment is due on date of signup or renewal i.e. first • Half upon completion
day of the membership year. • Workshop books are priced roughly at cost, and must be paid in full
• The second installment is due 6 months into membership year. when registering.
Both payments must be received on time for access privileges to be Both registration payments must be received before being certified as
extended. having completed the workshop.

2. Fee Reduction Eligibility verification required for fee reduction .

Those unable to afford full payment over an extended schedule may apply for fee reductions as follows:
 Senior Citizens (65 and over) can apply for a reduction of up to seventy-five percent on their Full membership fee.
 Students (under 18) can apply for a reduction of up to seventy-five percent on their Full membership fee.
 Limited income applicants can apply for a reduction of up to seventy-five percent on their Full membership fee and up to fifty percent on
classes over $25.

Please fill out this form to apply for alternative payment.

Name: _____________________________________________________________________________________

Home Address: __________________________________________________________________________ _____

Mailing Address (if different): __________________________________________________________________________

Home Telephone: (___)_____________ Alternate Telephone: (___)_______________

E-mail address: ___________________________________ Birth Date (if under 18 or over 64): ______/_____/_____

_I am a Senior Citizen (65 and over, age verification attached)

_I am a Youth (under 18, age verification attached) Which payment alternative(s)
_Limited income (eligibility verification attached)
are you applying for?
Applicant hereby warrants and represents that the information supplied and
statements made above are true and applicant has not omitted or
Fee reduction ____
misrepresented any relevant information.
Signature _____________________ Date _____/_____/_____ Deferred payment____

Print Name and Signature of Parent or Guardian, if applicant is less than 18

years of age
________________________ ______________________________
Print Name Signature

3025 Washington Street | Boston, MA 02119 | Tel 617-708-3200 | Fax 617-708-3210 | www.bnntv.org
As of: 2/15/11 You Can Only Get It Here!
 BNN FEE REDUCTION ELIGIBILITY
GUIDELINES FOR LIMITED INCOME
APPLICANTS FOR 2011
Revised Feb. 10, 2011

Family Size Annual Income*

1 $16,335
2 $22,065
3 $27,795
4 $33,525
5 $39,255
6 $44,985
7 $50,715
8 $56,445
Each Additional $5,730

• BNN will only accept the following as verification of income:

1. Copy of most recent W2
2. Wage printout from the following offices:
a) Social Security
b) Department of Welfare/EBT
c) Child Support Enforcement Unit

• All forms must specify a dollar amount based on previous year’s earnings.
• Income guidelines are based on 150% of 2011 federal poverty guidelines as determined by the
Department of Health and Human Services.
• Confidentiality is maintained.
• If you have any questions, please contact BNN’s Membership Coordinator at 617-708-3224.

3025 Washington Street | Boston, MA 02119 | Tel 617-708-3200 | Fax 617-708-3210 | www.bnntv.org
As of: 2/15/11 You Can Only Get It Here!