*Name                                                             *Title/Assignment                                        *Photographer?
    select yes no

Name                                                               Title/Assignment                                         Photographer?
    select yes no

Name                                                               Title/Assignment                                         Photographer?
    select yes no

*Date/Time of Arrival On-site


*Media Affiliation


*Web site of Media Affiliation


*Address


*City                                                                              *State                                         *ZIP
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*Business phone                   Fax                                         *Cell phone
         

*Email Address


*Type of Media
select Print Radio TV Internet/Web site Other (please explain below)

Describe planned coverage/assignment:


*Additional Team Members Who Will Be Present (w/ titles):


Special Notes & Information:


*This form has been completed by:                     *Title