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Media Inquiry

Allegan County Health Department Media Inquiry Form

1. General Info *This question is required.

Space Cell	Fill
Name	Name: Fill
Email	Email: Fill
Phone	Phone: Fill
Title (Reporter, Editor, etc.)	Title (Reporter, Editor, etc.): Fill

2. Type of media outlet *This question is required.

Please enter an 'other' value for this selection.

3. Reason for request *This question is required.

4. Outlet Name *This question is required.

5. Is an interview required? *This question is required.

6. How much time is needed for your interview? *This question is required.

7. Where can the interview take place? *This question is required.

Please enter an 'other' value for this selection.

8. What information do you need from ACHD? (Please be specific so we can provide the most accurate information) *This question is required.

9. Is there any additional information that might help us respond accurately and in a timely manner?
*This question is required.

10. Have you contacted any other sources for interviews or information? If so, whom have you contacted?

11. What is your deadline? *This question is required.