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2. Media Inquiry Topic*
4. First Name
5. Last Name
7. Phone Number*
9. Email Address*
11. Media Outlet Name
13. Role
15. Type of Outlet*
17. Have you contacted anyone else?
    E.g. Another Municipality
19. Media Inquiry Description:
    Please include details regarding the story you're working on and specific information or questions for the City of Coquitlam.
21. Deadline Date
    Deadline Date
22. Deadline Time
    Deadline Time
23. Deadline ASAP

    1. ASAP
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field