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Television Membership Application

Television Membership Form

Licensee Information

Licensee Name *
Licensee Phone *
Licensee Email *
Licensee Mailing Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Station Information

Call Letters *
Channel *
Network *
Station Phone (if different from above)
Station Email (if different from above)
Station Website
Logos

Station Staff

Station Manager Name *(first, last)
Station Manager Email (if different from above)
Sales Manager Name (first, last)
Sales Manager Email
Program Director Name (first, last)
Program Director Email
News Director Name (first, last)
News Director Email
Engineer Name (first, last)
Engineer Email
Click below for a form to add additional stations.
Additional Stations Form
Additional Stations Form (Upload) Upload your additional stations form here.

Member Dues Payment & Instructions

Membership Dues *
Click HERE to see the dues grid and markets.
Choose a Payment Schedule *
AnnualBi-AnnualQuarterly
Payment Instructions
Once you click "Submit" below, you will be redirected to a PayPal page.

IMPORTANT: Make sure BEFORE paying online that your company has not already mailed a renewal check to the CBA. If a PayPal refund is required, PayPal fees from the original transaction will not be refunded.

You will have two options for online payment:

1. Pay with your PayPal account
2. Pay with a credit card

To pay with your existing PayPal account, simply enter your password and login.

To pay with a credit card, click "Pay with a debit or credit card, or PayPal Credit" or "Don’t have a PayPal account?"

Verification

Please enter any two digitsExample: 12
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