2. Request from media for interview
4. Type of Request

   1. Public Education
   2. Incident Related
6. Date for Interview
   Date for Interview
7. Time(s) for interview
9. Interview Type

   1. Taped
   2. Live
11. Description of interview requested:
13. Name:
    First and Last Name
14. Media Affiliation
16. Contact Phone Number:
17. Email:
Leave This Blank:


19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

* indicates a required field