Media Relations Intake Form
Please use this form if you are seeking use of Urban Homestead facilities, story, or similar for Public, Social, News, or other Media-related engagements and arrangements.
Name of primary Media Organization through Which Urban Homestead content will be distributed *
Your answer
Name of Show or Segment *
Your answer
Are you authorized by the primary Media distribution Organization listed above to contact and represent the Organization? *
Your Name *
Your answer
Your eMail *
Your answer
Your Mobile Number
Your answer
Your organization name used to represent if primary Media Organization *
Your answer
What kind of engagement is being proposed?
What day is the Media Event currently scheduled for? *
MM
/
DD
/
YYYY
Notes
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Urban Homestead Inc.. Report Abuse - Terms of Service