Age of Chivalry Media Request Form
All Requests must be submitted no later than Friday, October4 to be considered.
Name
*
First Name
Last Name
Outlet Name
*
Outlet Website
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Coverage Requesting
*
Print
Radio
TV
Online
Social Media
Other - specify below
Other Coverage Type
Intended Coverage
*
Assignment Editor (Student)
Date Requesting Credentials
*
Friday, October 11
Saturday, October 12
Sunday, October 13
Number of Credentials Requesting
*
Full Names and Titles of All Staff Needing Credentials
*
Additional Details
Submit
Should be Empty: