2017 NQC Media Request Form
Please remember that you are allowed 2 media credentials per media outlet. If a parent company owns more than one media outlet, the parent company can fill out a request for each outlet.
Company Name
Name of Media Outlet
Your answer
Name of General Manager, Program Director or Immediate Supervisor
This should be the name of the main decision maker for your media outlet
Your answer
Website
Give the web address for your media outlet website. Parent company website would be fine
Your answer
State
State where your media outlet is located
Your answer
Representative 1 First Name
Your answer
Representative 1 Last Name
Your answer
Representative 1 e-mail address
Your answer
Representative 2 First Name
Your answer
Representative 2 Last Name
Your answer
Representative 2 e-mail address
Your answer
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