MEDIA OUTLET:       

OUTLET WEBSITE:   

REQUESTED BY:         

EMAIL: 

OFFICE PHONE:              CELL PHONE:  

MEDIA TYPE:      TV     
                                RADIO
                                INTERNET
                                PHOTOGRAPHY
                               

 Please list the names of STAFF who are authorized to represent your organization.

STAFF NAME 1: 

STAFF NAME 2: 

STAFF NAME 3: