General LWC Media Information
Name (First & Last) *
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Media Outlet/Organization *
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Email Address *
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Mobile Phone/Business Phone *
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Address, City, State, Zip *
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Type of Organization *
Circulation/Viewership *
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Name of Assigning Editor/Publisher/Producer *
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Editor/Publisher/Producer Phone *
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Editor/Publisher/Producer Email *
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Medium *
Description of Assignment(s)
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Intended Date of Publication
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