Accreditation

Accreditation Form

Planning to attend DisOrient as an ARTIST, INDUSTRY, or PRESS representative? Please complete this ACCREDITATION FORM to let us know that you are planning to attend no later than April 20th, 2013. Please fill out one form per person. DisOrient reserves the right to limit the number of complimentary passes per film or organization.

Full Name(required)

Email(required)

Mailing Address

City, State, Zip Code, Country

Phone

Job Title(required)

Film(s) or Organization(s) You Represent(required)

Role that Best Describes your Participation at DisOrient(required) Producer Director Screenwriter Songwriter Actor Agent Film Distributor Exhibitor Festival Programmer Film Festival Representative TV/Radio Print Media Photographer Blogger DisOrient Staff/Alum CABA Board Member OTHER

If marked OTHER, please specify

Mode of Transport(required) Airplane Car Train Bus OTHER

What date will you arrive?(required)

What time (AM/PM) will you arrive?

Arrival Details (please describe

What date will you depart?(required)

What time will you depart?

Departure Details (please describe)

Where will you be staying while in Eugene, Oregon? (Please list name, address, and phone)

Is this a Hotel/Motel Private Residence

Are you interested in exploring home-stay opportunities with DisOrient? (If yes, Hospitality Chair will contact you with more information)(required) Yes No I don't know

Please indicate if you have any additional needs here

Please select your T-Shirt size x-small small medium large x-large xx-large