Interview Request Form Name * First Name Last Name Media Outlet * Email Address * Telephone Number Website http:// Type of Media Please indicate print, radio, television, online, podcast, etc. Media Market/DMA or Geographic Coverage Circulation/Audience Requested Date Requested Time Please indicate AM/PM & Time Zone. Interviewer Who would you like to interview? Length of Interview Live or Taped? Telephone? Email? In-Person Interview? Topic or Focus of Interview Run Date or Publication Date Details and Special Requests Please provide complete details and special requests. For radio interviews, please confirm producer name and back-up telephone number(s). Thank you!
