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2. Please complete and submit this form at least 2 weeks prior to the anticipated film date. You will be notified of the Superintendent's decision at least 24 hours in advance of the film shoot. If approved, the signed approval letter must be available at the site of the film shoot.
6. Contact First Name*
7. Contact Last Name*
9. Business Name
11. Email*
13. Daytime Phone*
14. Fax
16. Address
18. City
19. State
20. ZIP
24. Date & Time of Film Shoot*
    Date & Time of Film Shoot Start Date

    Date & Time of Film Shoot Start Time

    —

    Date & Time of Film Shoot End Date

    Date & Time of Film Shoot End Time
26. Location of Film Shoot*
28. Description of Scene to Shoot*
    Provide a brief but thorough description of the scene you wish to film. Be sure to indicate any action(s) that might be construed as violent and/or alarming to passers by. Indicate any special needs related to traffic or pedestrians.
30. Is this scene considered a "violent" scene?*

    1. Yes
    2. No

    Violent scenes are those that include violence, including fake fighting, or use prop or real weapons. For violent scene requests, certificates of insurance must state coverage for the violence or use of a prop/real weapon. The city reserves the right to change the limits based on the application, and depending on the scene, may require more than two weeks to process the request.
32. If yes, Please provide a brief but thorough description of the action(s) that might be construed as violent and/or alarming to passers by and indicate any and all prop/real weapons being used.
34. Do you agree to clearly post the area around the film shoot with signs indicating to passers by that there is a film shoot in process and they should not be alarmed by actions or the use of weapons during the shoot? Signs should be made out of poster board, with large bold type, placed around the entire shoot area.*

    1. Yes
    2. No
36. Do you agree that if at any time during the shoot, you are asked to stop filming by the Ithaca Police Department, you will do so immediately?*

    1. Yes
    2. No
40. Note: Ithaca College Students must submit the (Risk Management) OFF CAMPUS Media Production – Film Shoot Requests form, in addition to the City of Ithaca request form. If/When approved by the City of Ithaca and the Dean’s Office of the Park School of Communications, Risk Management will then issue a Certificate of Insurance directly to the City of Ithaca.
    
    If you send us a message, you'll receive a Tracking Number allowing you to follow-up with your request, at your convenience.
    
    Information we receive may be considered public information which is subject to disclosure under current state law. Learn more about our Privacy Policy.
42. Certificate of Liability Insurance
    A certificate of liability insurance must be provided. If you have it, you may upload a pdf file.
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44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field