Media Pass Request

Date *
Name *
Company Address
Company Address
Cell Phone *
Cell Phone
Which Event Are You Applying For? *
Please Select One
What is your offical title? *
Please Select One or More
Full Name
What is their Cell Number? *
What is their Cell Number?
Example (Aunt, Brother, etc.)
Terms & Conditions 1. Only one press pass per company/publication 2. Tape recording is prohibited unless authorized in a written agreement prior to the date of the event. Anyone found tape recording an event will be asked to leave the event. 3. Any photos/videos taken by me at this event will be used in the performance of my duties/responsibilities with the company listed above and will not be resold without prior written permission from the Mrs. Pennsylvania America Organization. 4. I agree to provide the Mrs. Pennsylvania America Organization with two (2) copies or 1 Dropbox link of the work published, aired, or printed as a result of my assignment via hard copy or email. 5. Mrs. Pennsylvania America has the right to publish these photos, video or written verbiage at their discretion.