Contact

    1. Name

    First Name (required)

    Last Name (required)

    Title

    2. Your Email Address

    Work Email

    Personal Email

    Which email is the best place to email you?

    WorkPersonal

    3. Company (skip this area if you are strictly freelancing)

    Company Name

    University (if affiliated with one)

    Type of Media (Newspaper, Magazine, TV Program, Website, Radio Syndicate)

    How often do you publish or air?

    If other, please describe

    How would you describe the primary editorial focust of your outlet (Rock, Country, General News, Entertainment News, Men, Women, Teens, Farm Machinery, etc.)?

    4. Your Location

    What is the major metropolitian area nearest to where you live?

    Addresses

    Please provide us with your address. Only one is required, but as many as you'd like to give us would be appreciated. If you only give us one address, please be sure it is the same one you just identified as your Primary Mailing Address. Also, if your primary mailing address is a P.O. Box, also give as a street address in case we need to use an overnight service that won't deliver to a P.O. Box.

    Home/Personal Address (Street Address)

    Address 1

    Address 2

    City

    State

    Zip

    Work Address (Street Address)

    Address 1

    Address 2

    City

    State

    Zip

    Work (P.O. Box)

    Address 1

    Address 2

    City

    State

    Zip

    5. Your Phone and Fax

    Work Phone and Extension

    Work Fax

    Home Phone

    Home Fax

    Cell Phone

    6. Your Work

    Is there a way we can look at your work online?

    Work URL

    Personal URL

    7. Your Freelance Information

    List the outlets you freelance for (up to 10)

    Your notes/comments