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Québec City's 400th anniversary
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Assistance request form
for freelance-journalist

  General Informations
Title 
First name 
Last name 
Address 
Address 
City 
Province / State 
Postal / ZIP 
Country 
Phone  extension
Fax  code
Email  
  Informationabout the media
Name of the publication or company
Address 
Address 
City  
Province / State  
Postal code / ZIP
Country  
Phone   exntesion 
Fax   code
1-800 Number 
Email  
Web site 
Editor-in-chief 
Phone   extension
Email  
Section head (tourism, travel or other) 
Phone   extension
Email  
Type of 
publication 
(content) 
Format 
Circulation / share of audience 
Target audience 
Coverage 
Frequency (daily, weekly, etc.) 
Advertizing fees for a page in colour 
Advertizing fees for a b&w page
Other publication 
Circulation / share of audience 
  Travel informations
Confirmed date  of arrival 
Confirmed date  of departure 
Would you be interested in obtaining free accommodations?  Yes 
No
If yes, will you mention the name of the hotel in your story?  Yes 
No
If it is not possible to offer you free accommodations, would you accept to pay the media representative rate?  Yes 
No
If yes, how much are you willing to pay? 
Number of people in your group (if applicable)  Include their names and titles:
 
Type of story 
Special interests (ex: shopping, local cuisine...) 
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  Send me a media kit


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