Request For Interview Form Date(Required) MM slash DD slash YYYY Name of Reporter(Required)Reporter Email Address(Required) Reporter Phone Number(Required)Name Of Media Organization(Required)Interview Topic(s)(Required)Will any individual, entity, investigation or court case be referenced as part of the story?(Required) No Yes If you answered yes, please provide the names of all individuals, entities, investigations or court cases.Specific questions to be asked of Coalition representatives:(Required)Preferred format for Coalition response: (Check all that apply)(Required) Written Comments Virtual Interview In-Person Interview Time frame in which a response or interview is needed?(Required)What media format(s) will the interview be shared on? (Check all that apply)(Required) Television Print Social Media Radio Website Will any of the following be requested? (Check all that apply)(Required) High Resolution Coalition Logo Description Of The Coalition Do you agree to fully adhere to the Coalition's Media / Interview Policy, as outlined on our website?(Required) Yes No If you answered no, please indicate why you are unable to fully adhere to our media / interview policy?Any other details of factors you would like to provide about this request? Δ