Name of Media Organization
Media Organization URL
Reporter's First & Last Name
Record the full name of the media representative.
Type of Request
Information or Fact Checking
Comments and Quotes for Story
Number of Media Passes Requested?
Media passes are based on availability and reserved for working members of the press.
Nature of Request
What is your story angle? List any specific questions.
Is there a specific individual you would like to interview?
Will you bring a large camera or media equipment?
Reporter's Email Address
Reporter's Phone Number
Reporter's Social Media Accounts
Recent articles and media reports
Enter links to the reporter's recent articles and reports
or attach PDF versions of the articles and media reports
Send me a copy of my responses
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