APPLICATION FOR CERTIFICATE OF
INTERNATIONAL EDUCATIONAL CHARACTER
U.S. Department of State
Title of Program (or Series)
Producer
Director
Intended Audiences
GENERAL INFORMATION
Grade Level
Black and White
Color
Negative
Positive
Sound
Silent
Program Format
Slide/Transparency
Wall Chart/Map/Poster
Model
DESCRIPTION OF SLIDE OR TRANSPARENCY
Slides/Transparencies
In. By In.
Number
Size
Records
Numbers
Size
Cassettes
Number
DS-2038 (Formerly USIA IAP-17)
02-2006
Motion Picture/Videotape/Videodisc
Recording (Includes CD/CDR/DVD Products)
Other
Date of Production (mm-dd-yyyy)
Date of Release (mm-dd-yyyy)
Page 1 of 2
Summary of Content
Address of Applicant (Street, City, State, Zip Code)
Language(s) Used In
Name of Applicant (U.S. Holder of Basic Rights) (Last, First, MI)
DESCRIPTION OF MOTION PICTURE/VIDEOTAPE
Form
Format
DVD
Cassette
Diskette
CD-CDR
Number of Units
Length in Time
DESCRIPTION OF WALL CHART/MAP/POSTER
Wall Chart Map
Other
Poster
Constituent Material
Dimensions
By
Bound
Single
Sheets
Sets of
Sheets
DESCRIPTION OF MODEL
Dimensions
Length
Height Width
Moving
Static
Predominant Colors
STATEMENT OF OWNERSHIP
Type or Print
Signature
Date (mm-dd-yyyy)
Telephone
E-Mail Address
* If materials are not fully owned by applicant, please explain or attach documentation.
ATTACH TO THIS APPLICATION A COMPLETE DESCRIPTION OF THE MATERIAL WITH THE EXACT WORDING OF TITLES,
COPIES OF GUIDES, ETC., AND FORWARD THE MATERIAL, PREPAID, FOR REVIEW.
RETURN COMPLETED FORM
Fax Number: 202-203-7469
ECA-IIP/EX
Attestation Officer of the United States
U.S. Department of State
301 4th Street, SW
Washington, DC 20547
I,
, hereby certify the applicant named
above is the owner of the basic rights to the material(s) described in this application.*
Title
Constituent Materials
Scale
Gauge
Length In Feet
Gauge
Cassette
Running Time
Hours
Minutes
Videotape
DESCRIPTION OF RECORDING
Motion Picture
Page 2 of 2
Other
Description of Videodisc and other Motion Media Formats
Telephone Number: 202-203-7447
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signature
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