Authentic Media & Brand Intake Form
Questionnaire
Name
*
First Name
Last Name
Organization
Phone Number
*
-
Area Code
Phone Number
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Personal Website
LinkedIn url
Facebook page
YouTube
Instagram
Other
What is the return on investment for one client? (How much is one client worth to you?)
$
blanks
How could media improve your business or brand?
*
What type of Media are you interested in being placed or featured?
Podcasts
Print publications (i.e. Magazines, newspapers, etc.)
Blogs
Your own media
Social Media
Other
Which podcasts, blogs, television, magazines, or social media are your favorites to consume currently?
*
Which media would you like to appear? Why?
*
If possible, please share any links to past speaking engagements or media you've had.
How did you hear about us?
Google Search
Referred by someone
I'm a listener
Social Media
Other
Is there anything else you'd like to add?
Please verify that you are human
*
Submit
Should be Empty: