| Your Name |
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| Your Title |
|
| Which Branch of Service: |
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| Organization Name: |
|
| Contact Info for Organization |
|
| Supervisor's Name/Contact Info. (if different than above) |
|
| Your Email Address: |
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| Brief Organization Description: |
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| Main Issue: |
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| Brief Overview of the Issue: |
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| Who are your clients/target market? |
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| How are they impacted by this issue? |
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| What are you doing to solve the problem? |
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| If needed, can you provide personal interviews/stories of the people who are impacted by the issue? |
| YesNoSometimes |
| Can you provide photographs? |
| YesNoSometimes |
| Does your organization have facts, studies or other background information? |
| YesNoSometimes |
| Do you have an online Media/Press Page on your Website with additional information? |
| YesNo |
| What is your Website Address? |
|
| Other Issues that you're working on: |
|
| Please list the best times to reach you or provide additional contact information (such as a cell phone) |
|
| Do you provide media training for your spokespeople? |
| YesNoSometimes |
| If no or sometimes, would you like resources and training info. on the Website? |
| YesNo |
| Please rate your organization's level of experience in working with the media (this question is for statistical purposes only, and will not affect your chances of being chosen as an expert) |
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| What is your biggest challenge having to do with getting media coverage for your organization? |
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| Please provide any other information that you think would be helpful: |
|
Your Name:
Your Email: |
