Media Credential Request Form
For the Clarksdale Sinners Screening
Name of Media Credential Requestor
First Name
Last Name
Job Title
Email
example@example.com
Phone Number
Please enter a valid phone number.
Organization Information
Organization Name
Organization Type
Print
Radio
TV
Photo
Video
Press
Blog/Website
Social Media/Influencer
Podcaster
Organization Address
Street Address
Suburb
State
Post Code
Organization Website
Media Credential Type: Select all that apply.
Photo
Video
Press
Photographer
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Website/Portfolio/Social Media URL
Twitter, Facebook, Instagram, LinkedIn, YouTube, etc.
Videographer
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Website/Portfolio/Social Media URL
Twitter, Facebook, Instagram, LinkedIn, YouTube, etc.
Press Representative
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Website/Portfolio/Social Media URL
Twitter, Facebook, Instagram, LinkedIn, YouTube, etc.
Additional Comments
Submit
Should be Empty: