Media Form to Interview Jorge

News outlet name

Contact name and title

Contact email

Contact phone

Deadline

Request type

Interview Written reply Info Other

If an interview

Location and reach of outlet

Social media accounts

Specific show/program/section (if applicable)

Topic(s) of query

Name and title of interviewer (if different from contact)

Email of interviewer (if different from contact)

Phone of interviewer (if different from contact)

Questions/discussion topics

Time required

Preferred plantform

Special requirements

Other comments/questions