Media- Interview Request Form

CHPP Media Interview Request Form
Name

First NameLast Name
News Outlet
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Interview Date Request

MonthDayYear
Date
Interview Time

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Alternative Interview Date

MonthDayYear
Date
Interview Length

ex: 00:30
Deadline to Confirm Interview

MonthDayYear
Date
Type of Interview

Face-to-face / In personTelephone LandlineCellphone/FacetimeSkypeZoomInstagramFacebookOther
Location and reach of outlet
Social Media Handles
Name of desired interviewee or area of expertise
Questions/Discussion Topics
Special Requirements
Other comments/Questions
Should be Empty:

CHPP Media Interview Request Form