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