Please print this form, complete, and mail to: KSFY Television 300 N. Dakota Ave. Suite 100 Sioux Falls, SD  57104

NAME: _______________________________________ TELEPHONE:________________________

ADDRESS: ________________________________________________________________________

CITY: ____________________________________ STATE: ________________ ZIP: _____________

Describe the story you are requesting, including the date and time of the newscast on which it aired.
   * Limited to the following newscasts - KSFY News at 5pm, 6pm & 10pm, and Sunday at 5:30pm.

______________________________________________________________________________________

______________________________________________________________________________________

The material you are requesting is copyrighted by KSFY-TV. You are receiving it solely for home use and by signing this form agree:

1. The video may not be broadcast or published by any media, including posting on the Internet.
2. The video may not be used for any commercial/promotional purpose.
3. The video may not be copied by a third party.
4. The video may not be used in any litigation.

Signed: ____________________________________________ Date: __________________________

Please provide a check or money order made out to KSFY Television.  Do Not Send Cash.