Press / Media Request Form

Press / Media Request Form
*Serious inquiries only*

All interview / media requests must be submitted through the webform below.
Requestor Details
Requestor Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Are you a member of the press / media?

YesNo
Press / Media Outlet Name*
Website*
Press / Media Type*

TelevisionRadioPrint (Magazine, Newspaper, etc.)Website (blog, digital / online journalism)Social Media / Streaming Journalism (Youtube, Daily Digital Show, etc.)
Distribution / Reach*

LocalRegionalNationalGlobal
If you are not a member of the press / media. Please provide your organizational details.
Organization
Organization Type
Website
Budget / Honorarium Offer
Currency: USD
Interview Details
Name of person who will conduct the interview*

First NameLast Name
Topic to be covered*
List of questions to be covered in interview. (This list can also be uploaded as a separate document below) *
Upload questions (if not listed above)

File Types: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Please describe what you hope your audience will gain and/or learn from the interview? (provide as much detail as possible)*
Interview Date (first option)*

MonthDayYear
Date
Interview Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Interviewer's Timezone*
Alternative date options: Please provide additional date options in case your first date selection is not available.
Interview Date (second option)

MonthDayYear
Date
Interview Time

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Interview Date (third option)

MonthDayYear
Date
Interview Time

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Deadline to receive interview confirmation*

MonthDayYear
Date
Expected Interview Duration (minutes)*
Interview Format (How will the interview be conducted?)*
Location where the interview will take place*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Will the interview be recorded or published?*

YesNoNot determined
Where will it be published?
Please verify that you are human*
Should be Empty:

Press / Media Request Form

Requestor Details

Interview Details