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Name of Organization *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

If you are based in the U.S. but work for an outlet that serves a foreign audience, please indicate the country your outlet serves.
Phone Number * ### - ### - ####
Fax Number * ### - ### - ####
Email Address *
Supervisor/Employer's Information
Supervisor/Employer's Name * Title First Last Suffix
Supervisor/Employer's Title *
Supervisor/Employer's Phone Number * ### - ### - ####
Supervisor/Employer's Fax Number * ### - ### - ####
Supervisor/Employer's Email Address *
Website
Please Indicate your Outlet
Print Media
National Local
TV
National Regional Local
Radio
National Regional Local Website
Wire Service
Syndicate Photo
Please briefly describe your target audience, subscribers, or readers (demographic information) *
Reach/ Circulation/ Distribution- Briefly describe how many households, readers, or subscribers you reach and how often to reach your audience.
Media that require more than the allowed credentials must pay for a retreat badge (at discounted rate of $150).

MEDIA CHECK-IN
2007 Global Mixx Music Retreat Media Check-in will be open beginning Friday, July 20, 2007. Media credentials must be picked up in person by each individual person.

ON SITE: You will be asked to sign in with name, media affiliation, telephone number and address and/or business card.
Please list your staff by name. The total number of names below should be the same as the number of credentials you are requesting. List the legal name (as printed on ID) of staff or crew member. Refer to the guidelines for limitations per event and per outlet.
Member Photo 1

(upload 2x2 passport size photo)
Member Photo 2

(upload 2x2 passport size photo)
Member Photo 3

(upload 2x2 passport size photo)
Member Photo 4

(upload 2x2 passport size photo)
By requesting, claiming and/or using media credentials, you agree to abide by all event regulations and media guidelines. These guidelines will be available at credential claim and may be amended or changed without prior notice. *
I Agree
By submitting this, I agree, if granted media credentials, to cover The 2007 Global Mixx Music Retreat and further agree to submit a copy of post-event coverage to Chatterbox Publicity, LLC. *
I Agree
Do Not Fill This Out

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Supervisor/Employer's Information

Please Indicate your Outlet