* 1. What is the name of your media outlet? 

* 2. What is your website url?

* 3. What is your mailing address?

* 4. What is your primary format? 

* 5. What are your additional formats?

* 6. How long has your company been in business?

* 7. What is your distribution? 

* 8. What is the frequency of your distribution?

* 9. What are your circulation/viewership/reader numbers?

* 10. What is the name of the primary contact at your organization?

* 11. Primary contact email address:

* 12. Primary contact phone number:

* 13. Number of passes you are requesting:

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