Your Name

Email Address

Phone Number

Organization / Publication

Website or Portfolio Link

What type of inquiry is this?

Interview (written / audio / video)TV / RadioFeature ArticleOther

What is the focus or angle of the story?

What topics would you like to discuss?

Why are you interested in speaking with me specifically?

Who is the intended audience for this piece?

Audience Size / Distribution

What is the expected length or depth of the interview/piece?

Will the interview be live or pre-recorded?
LivePre-recordedEdited

Specific Talking Points

Requested Interview Date(s)

Deadline

Estimated Duration

Time Zone

Expected Publication / Air Date

Will I have an opportunity to review for accuracy?
YesNo

Will you provide a copy of the final piece?
YesNo