Name of Media Organization*

Media Organization URL*

Reporter's First & Last Name*
Record the full name of the media representative.

Type of Request*
B-RollFilmingInformation or Fact CheckingMedia PassMedia InterviewMedia TourPhotosOtherComments and Quotes for Story

Number of Media Passes Requested?
Media passes are based on availability and reserved for working members of the press.

Desired Visit Date
Verify selected desired date before submission; passes will not be reissued. Request for weekday media passes are preferable; weekend passes are limited.

Nature of Request*
What is your story angle? List any specific questions.

Preferred Interviewee
Is there a specific individual you would like to interview?

Will you bring a large camera or media equipment?

Filing Deadline

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

Email address

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