16th Street Baptist Church Media Form

16th Street Baptist Church Media Form

1530 6th Avenue North, Birmingham, Alabama 35203 205.251.9402
Editor/Writer/Reporter/Producer/Photographer/Broadcaster/Camera Person/Blogger/Other
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
Confirm Email*
Phone Number*

Area CodePhone Number
Event Name*
Event Date*

MonthDayYear
Location name*
Media Outlet*
Media Type*

PrintTVInternetRadioOther
Facebook URL
Twitter Handle
Website
Detail Circulation Numbers
Detail Monthly Unique/Visitor (If applicable)
Describe your Audience
Job Title*

EditorWriterReporter (TV/Radio)ProducerHost (TV/Radio)Photographer/Camera PersonBroadcasterBloggerOther
Assigner's Name (If different than Media Applicant for accreditation purposes)*
Detail your Intended Event Coverage
Additional Comments
A Copy of Issued Photo/ID (Must be valid and current)

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