First Name	Last Name
Title	Company
Phone	Email
Address	City
State	Zip
Web Address

Are you the primary media contact for your company?    Yes No   If no, please provide primary media contact information

What would you like the title of your Press Release to be?

What is the key message you wish to convey to your audience?

Please tell us if there is any other information that you would like to include in your press release

On what level are you looking to reach prospects?    Locally Regionally Nationally

If locally, please provide 3 local publications you wish to have your press release submitted to:

Publication 1	Phone number/website
Publication 2	Phone number/website
Publication 3	Phone number/website

If regionally or nationally, do you want to have online search optimization?   Yes No

Start Building Your Buzz!    Press Release