ALLY Screening Form Screening Application Form We’re excited to work with you! Thank you for helping us spread the word about A LOT LIKE YOU. Please complete this application and return with the appropriate payment to the address below. Once received, we will promptly add your event to our growing calendar/map of screenings and send you a DVD. STEP 1Name* First Last Phone*Email* Mailing Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Organization and/or SchoolOrganization Website Screening date* Screening Time* : HH MM AM PM Name of venue where you'll be screening A LOT LIKE YOU*Street address of screening venue* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country STEP 2All public screenings of A LOT LIKE YOU require the purchase of community screening rights. Please note that these rights pertain only to your group and cannot be transferred, lent or sold to another party. From the options available below, please let us know which choice best for you.HOME SCREENING PACKAGE Price: $29.99 Quantity: If you are interested in hosting a house party (up to 20 people), choose this option. This is a great way to bring together friends, family, neighbors, and co-workers in a comfortable environment.ADMISSION FREE SCREENING PACKAGE Price: $100.00 Quantity: If you are interested in hosting a free-to-the public screening of 100 people or less to keep your overhead low, choose this option. These rights cover a one-time-only public viewing of the film.FUNDRAISER SCREENING PACKAGE Price: $150.00 Quantity: If you’ll only show the film publicly once to less than 100 people, please use this option. You are welcome to charge admission.5 SCREENINGS PACKAGE Price: $350.00 Quantity: If you wish to show the film publicly on multiple dates to a crowd of 100 or less, please choose this option. These rights cover up to five viewings of the film, and you are welcome to charge admission. Rights are not transferable (i.e., you may not transfer the DVD or viewing rights to another group.)LARGE SCREENINGS and/or MORE THAN FIVE SCREENINGS Price: $0.00 Quantity: If you wish to show the film publicly to a crowd of more than 100, or purchase more than five screening licenses, please send us an email at info@alotlikeyoumovie.com. We encourage big screenings and multiple showings but need to determine the fees on an individual basis. STEP 3Many groups find it helpful to purchase a bulk order of A Lot Like You home-use dvds to resell for fundraising purposes. If this interests you, please note the number of DVDs you’d like, and include the corresponding amount in your payment. Prices include shipping.Bulk order of ALLY DVDsPack of 5 DVDs ($100 Retail) for $75.00Pack of 10 DVDs ($200 Retail) for $125.00Pack of 20 DVDs ($400 Retail) for $200.00STEP 4Would you like Director Eliaichi Kimaro to attend your screening event to present the film and engage your audience in a post-screening discussion? Yes No *Due to heavy demands on her schedule, Ms. Kimaro can only attend where an honorarium plus travel expenses can be offered.Please indicate how you prefer to submit your payment.* I am paying by credit card. (To make a secure online payment, please visit our Square account page: http://mkt.com/a-lot-like-you/ally-screening-packages I am including a check. Please make payable to "9elephants productions". I, the undersigned,agree to purchase the community screening rights with the understanding that these rights pertain only to our organization and cannot be transferred, lent duplicated or sold to another party. MM DD YYYY