Program Submission Form

Your thoughts and opinions are important to the Development Team and KPBS! Please complete this brief survey. Thank you for your valuable input!

What do you feel are the most pressing needs in our community?

As someone who supports our programs, which of these topics or services offered by KPBS interest you? (Please check all that apply.)

News

Programming

Community Events

Digital

Other

Recognition

Would you like your name(s) to appear in the Producers Club Member listing?

No, do not list my/our name(s). I/we wish to remain anonymous.

Yes

List my/our Producers Club membership as ...

We respect your privacy. Your name(s) will be listed only if this form is received with your name(s) filled in above.

List my/our Producers Club membership as ...

We respect your privacy. Your name(s) will be listed only if this form is received with your name(s) filled in above.

Thank You Gifts

I/We would like ...

KPBS Producers Club license plate frame(s)

KPBS Producers Club polo shirt (limit 2)

Please allow 4-6 weeks for receipt of requested items.

License Plate Frame Quantity

Women's - Pale Blue

Sizes: S, M, L, XL

Men's - Steel Grey

Sizes: M, L, XL

Women's (1) - Quantity

Men's (1) - Quantity

Women's (1) - Size

Men's (1) - Size

Women's (2) - Size

Men's (2) - Size

How would you like us to stay in touch with you? *

Send me emails updating me on station information and topics

Call me on occasion

Send me invitations to events

Meet with me to talk about the greater mission of KPBS

I would like information on including KPBS in my estate plans

I do not wish to have any additional engagement with KPBS

Contact Information

Name (1) *

First Last

Name (2)

First Last

Email (1) *

Email (2)

Phone (1)

### - ### - ####

Phone (2)

### - ### - ####

Phone type (1):

Cell

Home

Work

Phone type (2):

Cell

Home

Work

Birthday (1)

MM / DD / YYYY

Birthday (2)

MM / DD / YYYY

Address type: *

Home

Work

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Questions about your Producers Club membership?
Contact Niru Ramachandran at nramachandran@kpbs.org or 619.594.2028.