Assistance request form freelance : Media

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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...)
Add me to your mailing list
Send me a media kit

Français / English
Español / Português

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