PR/Media Request Form
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Today's Date *
Your Name *
Phone Number *
Email *
Who are you requesting to be interviewed? *
Type of Media *
Name of Organization (Show, Publication, Newspaper) *
What is the estimated reach of your outlet? *
Will you be sharing the story/interview across your social media? If yes, what platforms and estimated social media reach? *
Length of Interview/Segment *
Proposed Date/Time (PST) Please add additional dates/times as options if possible. *
Requested Location (please specify Zoom, Skype, in-person, etc.) *
Requested Arrival Time *
Select all topics to be discussed: *
Point of Contact *
Time of Broadcast/Issue *
Deadline for Response *
Any other details? *
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