EmailMe Form - O.M.G Media Request Form

Journalist Name *

First Last

Date Of Birth *

MM / DD / YYYY

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Email *

Media Company Name *

Contact Name of Person On Site *

First Last

Phone Number of Contact Person On Site *

### - ### - ####

Journalist Phone or Parent/Guardian Phone, if under 18 years old, unless same as above

### - ### - ####

Parent or Guardian Name *

First Last

Media Category *

If Other, Please Specify

Web Site

File Upload sample of work

Comments and Questions

Journalist Signature *

Clear

Please note by signing this, you agree to comply with guidelines outlined for journalist at the O.M.G Conference. You agree that everything you stated is true to the best of your knowledge, and that the Outstanding Mature Girlz Organization, Missyradio Organization as well as Southern University and all its entities, are NOT responsible for ANY lost, damaged, or stolen goods. I understand that by signing this, I am responsible for MY OWN ITEMS. I will also keep my media credentials on at all times, or I will NOT be allowed in media room. I will fully participate in the O.M.G Conference,and have a good attitude.

Parent Signature, if under 18 Years Old

Clear

By Signing this, I agree to all terms in the above journalist signature statement.

Date *

MM / DD / YYYY