Interview Request Form "*" indicates required fields First Name*Last Name*Media Outlet*Email Address* Telephone NumberWebsite Type of MediaPlease indicate print, radio, television, online, podcast, etc.Media MarketCirculation/AudienceRequested Date MM slash DD slash YYYY Requested DatePlease indicate AM/PM & Time ZoneInterviewerWho would you like to interview?Length of InterviewLive or TapedLiveTapedMethodIn Person InterviewTelephoneEmailVideo CallTopic or Focus of InterviewRun Date or Publication DateDetails and Special RequestsPlease provide complete details and special requests. For radio interviews, please confirm producer name and back-up telephone number(s).