Media Request Form

Media Request Form

Thank you for requesting a service from Name's Blue Media. Make sure to fill out all required information below to insure approval for your request.
Name of Main Point of Contact*

First NameLast NameSuffix
Position & Title
Executive Director of Organization LLC
Your Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Website of Organization
www.example.com
Requested Service*

Film ProjectPhotographyEvent CoverageMarketing ProjectAuditory ProjectDesign JobNewsletter FeatureBranding Consultation
Project Title*
Provide a short title for the project
Requested Coverage Date*

MonthDayYear
Provide the date of the initial coverage. If there are multiple dates, please specify
Time Project Will Take Place*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Provide location of coverage*
Provide the name and address of where the event or project will take place.
Additional Locations
If there is more than one location, please provide the list of addresses of the locations (and name if available of locations). Provide if there is parking and where specifically.
Project Summary*
What are the details of the project? Please provide as much information as possible.
Project Goals/Objectives
What are the desired outcomes of this project? What are the key performance indicators? Outcomes should be specific, measurable, achievable, realistic, and time-bound.
Estimated Project Timeline
Key Deadlines of Project
If applicable, please provide the initial timeline of deliverables due. If there are multiple dates, please provide all dates and times.
Upload Additional Media

Please provide any additional information about the project such as weblinks, videos, pictures, PowerPoints, audio, or voice overs.
Cancelof
Provide The Type of Project*

Public ProjectConfidential Project
Does Name's Blue Media have permission to post or use content for promotional materials?*

YesNo
Select Method of Payment*

Invoice - Will Be Sent After Receipt of Media RequestCash Only
Did you check your submission for ALL grammar, spelling, and specific detail errors?*

YesNo
Should be Empty:

Media Request Form

Estimated Project Timeline