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Interview Request Form
For a Media Interview please fill out this form as best as possible. Please submit this form at least TWO WEEKS prior to your requested interview date if possible.
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* Indicates required question
Reporter’s name
*
Your answer
Email Address
*
Your answer
Media Type
*
Television
Newspaper
Radio
Magazine
Web News
Podcast
Other:
Media Outlet Name
*
Your answer
interview date
*
MM
/
DD
/
YYYY
interview time
*
Time
:
AM
PM
Topic specific question
*
Your answer
interview Deadline Date if any
MM
/
DD
/
YYYY
Is this interview in person
*
Yes
No
If yes what is the name of the business and address
Your answer
Will the interview be Audio or Video Recorded
*
Yes
No
Will you send us a copy of the interview if it is Audio or Video Recorded
Yes
No
Clear selection
Is this interview victual
*
Yes
No
Interview Format if victual
Zoom
Phone
Skype
Google Duo
Facetime
Other
Clear selection
Interview additional information
Your answer
Disclaimer
By submitting this form, it is not guaranteed a media interview someone will contact you as soon as possible when form is received.
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