Television/ Radio

Only interview requests submitted by individuals associated with official news agencies and recognized media outlets will be considered

First Name

Last Name

Email Address

Contact Telephone Number

Channel/Network

Program

Type of Program

Please specify if Other

Viewership figures

Please specify if Other

Interview to be conducted by

Proposed location for interview

Proposed date for interview

The Interview will be

Length of interview

Main topics to be discussed

Interview to be aired: (Date and time for the live and repeats)

Will the interview appear online?

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