Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Media Outlet
*
Name of Supervisor
*
Is this a class assignment?
*
Yes
No
In which format will the story be published?
Print
Radio
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Other
Requesting
Please Select
Staff Interview
Media Elements
Other (specify in comments area)
DEADLINE: Last possible date and time for an interview
*
-
Month
-
Day
Year
Date
Example: 1:50 PM
AM
PM
AM/PM Option
Preferred Interview Platform
*
Please Select
In-person / On-camera
Email
Phone
No Preference
Secondary Preference
*
Please Select
In-person / On-camera
Email
Phone
No Preference
Availability (For in-person interviews only)
*
Morning (between 8 a.m. and 12 p.m.)
Afternoon (between 12 a.m. and 5 p.m.)
No preference
Please specify the topic covered in the interview and provide a list of potential questions you would like answered.
*
Potential air or publish date
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Month
-
Day
Year
Comments
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