Ajamu Baraka - Press Request Form
Please use this form to submit all press requests for Ajamu Baraka.
Name of Media Outlet: *
Your answer
Brief Overview of Media Outlet/Show *
Your answer
Type(s) of Media Request *
Required
Name(s) of Interviewer(s) *
Your answer
What is the proposed date of interview? *
MM
/
DD
/
YYYY
Is there a latest possible date of the interview?
MM
/
DD
/
YYYY
Interview Location (City) *
Your answer
Interview Location (State) *
Your answer
What is the proposed length of segment? *
What are the proposed topics? *
Your answer
Is this request specifically only for Ajamu? *
Name of Contact Person *
Your answer
Email of Contact Person *
Your answer
Phone of Contact Person *
Your answer
Brief Additional Comments on Proposal
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Jill Stein for President.