Media Request 
Sign in to Google to save your progress. Learn more
Contact Information
Name
Email
Phone Number
Media Outlet/Publication Name:
Role/Title (e.g., reporter, editor):
Website URL:
Project Details

What is the topic or focus of your story?

What specific information or perspective are you seeking from us?

Are you looking to interview someone from our organization?

(If yes, please specify in "other" who are you requesting to interview (Name, title, or department)

What is the intended format of the piece?

Clear selection

What is the audience or demographic of your publication?

Logistics

What is your deadline for receiving a response?

MM
/
DD
/
YYYY
How are you planning to conduct the interview?

Do you have specific questions prepared for the interview?

What is the estimated publication or broadcast date for the piece?

Will you need images, logos, or additional materials from us?

If so, please specify below
Permissions & Follow-Up

Will you provide us with a copy or link to the final published piece?

Clear selection

Can we share your published piece on our website or social media?

Clear selection

Do you require any additional assistance or follow-up from us?

 If yes, please specify.
Is there anything else we should know about your inquiry or project?
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms