NEWS MEDIA REGISTRATION FORM Credentialing

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					                           NEWS MEDIA REGISTRATION FORM
Please complete the following form and submit it to Eleanor Maynard via email no later than close of
business on December 21 for credentials and access to the media viewing site for the demolition of the Lake
Champlain Bridge.


I am interested in covering the demolition of the Lake Champlain Bridge. I plan to be:                On

location at the bridge        Covering it from a remote location

URL of recent bylined article:




   I cannot produce a bylined article URL, and will attach other credentials as listed above to the e-mail.

Prefix:                    First Name:                 Last Name:



Position/Title:                          Publication/News Organization/Outlet:




Address:



City:                      State/Province:



Zip/Postal Code:           Country:



Daytime Phone #:           Fax #:



Email Address:             Web Site Address:




       By checking this box, I agree that I have read and understand the media registration instructions,
   security issues, and requirement, and will adhere to the no access zone requirements established for
   safety reasons. I have attached any required relevant documents.

				
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