Request for Interview Form

Please allow 72 hours for a response. Submittal of this form does not guarantee approval of interview.

1 Start 2 Complete

Requestor’s Name *

Requestor’s Email Address *

Requestor’s Phone Number *

Referred by (if applicable)

Length of interview (in minutes) *

Format *

Newspaper

Radio

Other

Audience for Interview *

Purpose of use of Interview *

Topic(s) of Interview *

Deadline for Interview *

Month

Day

Year

Leave this field blank

Campus Health & Wellbeing