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Attachment S ~ Public/Media Appearance Approval Form

(Please submit this form to Executive Director, Alpha Phi Alpha Fraternity, Inc., 2313 St. Paul Street, Baltimore, MD 21218, Fax (410) 554-0054 two weeks prior to anticipated approval)

NAME _____________________________________ E-MAIL ADDRESS___________________________

CHAPTER________________________________ FAX NUMBER ___________________________

Program Information

Television

Television network: ____________ Date and time show will air:

Name of show:

____________________________

_____________________________________________________________ Is show likely to air in syndication? _______________________________________________________

Radio Station call letters:

Name of show:

____________ __________________________________________ City: ___________ Date and time show will air: _____________________________________________ Is show likely to air in syndication? _______________________________________________________ Film

Production Company: ___________________________________________________________________ Name of movie: _______________________________________________________________________ Genre of film (Documentary, Fiction, Biography, etc): _________________________________________

How will ilm be distributed?

Film Festival

Theater

Straight to DVD

If distributed in theaters, where will it be shown?

Nationwide

Regional

Select Theaters

Role: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Press Release/PSA/AD

Please attach copy: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

I understand that my appearance constitutes a representation of the Alpha Phi Alpha Fraternity Inc. My words and actions are not only a portrayal of my reputation, but also the reputation of the General Organization. In this light, I commit to displaying the aims of manly deeds, scholarship and love for all mankind. I shall in no way misrepresent the Organization, any of its chapter, nor myself. I shall not divulge any fraternal secrets or the inner workings of the Organization.

~ For Official Use ~

Approved ____________ Date _____________________ Executive Director

Rejected ____________ Date _____________________ Executive Director

54

15th Draft 9/18/07

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