Media Credential Form

Please join us in the process by submitting your information below. Most fields are required.

Contact Information

Name:

Title:

Company:

E-mail:

Phone:Fax:

Optional: Specify an onsite setup contact, if different from above

Name:

Email:

Phone:

Company Address

Street:

City: State: Zip:

Media Information

Type of Media:

Newspaper
Magazine
Television
Radio
Online
Other

Are you broadcasting?

No Yes

Please specify broadcast dates/times:
Tuesday, 5/29 Start Time: End Time:
Wednesday, 5/30 Start Time: End Time:
Thursday, 5/31 Start Time: End Time:

Special Arrangements (check all that apply):

Electricity
Internet Access
ISDN Line
POTS Line
Tables
Chairs
Other

What will you be covering?

for media credentials

For more information, call Beverly Maddox 313.596.0343