Media Credential Request Form

Please type or print clearly:

Name:_____________________________________________________________

Title: _____________________________________________________________

Circulation/audience size: ____________________________________________

Address: ___________________________________________________________

Phone: _____________________________ Fax: __________________________

Pass needed (Check one): Reporter ___ Photo ___ Video ____ Other ____

Person to contact for assignment verification (name, daytime telephone):

*** Photocopy this form as needed. Use one form per request. ***

Credentials may be picked up at the NOW Action Center until 5 p.m., Wednesday, July 2. On-site credentials will be available in the NOW Press Office of the Peabody beginning at 10 a.m., July 3.

To link to this release: http://www.now.org/press/06-97/06-30-97.html