Media Credential Form

This form allows you to request media credentials and an interview. Upon receipt, your information will be recorded, reviewed, and a Public Relations staff member will contact you regarding the status of your request. In the interim, if you have an inquiry, please e-mail: publicrelations@tdjakes.org

Name:

Title:

Media Outlet:

Circulation/

Coverage

Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Email Address:

Interview Details

(Replace text where necessary.)

Desired Date:

Desired Time:

Est. Length:

Interviewer:

Preferred

Location:

Anticipated

Topics:

Anticipated

Publication Date:

Interviewed &

Additional Info.