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If you are media, please fill out this form Journalist Information First Name (as per photo ID): Last Name (as per photo ID): Date of Birth: Title: Email: Phone Number: (Please include area code and/or country & city code) Mobile Phone: Mailing Address: Address (cont.): City: State: --None-- ** - ** AB - Alberta AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona BA - Bayern BC - British Columbia CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware DK - Dnipropetrovsk ESS - Essex FL - Florida GA - Georgia HI - Hawaii HRT - Herts IA - Iowa ID - Idaho IL - Illinois IN - Indiana KEN - Kent KS - Kansas KY - Kentucky LA - Louisiana LAN - Lancashire MA - Massachusetts MB - Manitoba MD - Maryland ME - Maine MH - Marshall Islands MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana N.P. - New Providence NB - New Brunswick NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NL - Newfoundland and Labrador NM - New Mexico NS - Nova Scotia NSW - New South Wales NT - Northwest Territory NU - Nunavut NV - Nevada NY - New York OH - Ohio OK - Oklahoma ON - Ontario OR - Oregon PA - Pennsylvania PE - Prince Edward Island QC - Quebec QLD - Queensland RI - Rhode Island SA - South Australia SC - South Carolina SD - South Dakota SFK - Suffolk SK - Saskatchewan SRY - Surrey SX - Sussex SXW - West Sussex TAS - Tasmania TN - Tennessee TX - Texas UT - Utah VA - Virginia VIC - Victoria VT - Vermont WA - Washington WA - Western Australia WI - Wisconsin WV - West Virginia WY - Wyoming YT - Yukon Zip/Postal Code: Country: --None-- UNITED STATES CANADA MEXICO AFGHANISTAN ÅLAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA, PLURINATIONAL STATE OF BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANARY ISLANDS CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA CÔTE D'IVOIRE CROATIA CUBA CURACAO CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISLE OF MAN ISRAEL ITALY JAMAICA JAPAN JERSEY JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KOSRAE KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PONAPE PORTUGAL PUERTO RICO QATAR RÉUNION ROMANIA RUSSIAN FEDERATION RWANDA SABA SAINT BARTHÉLEMY SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAIPAN SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SCOTLAND SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA ST. BARTHELEMY ST. CHRISTOPHER ST. CROIX ST. EUSTATIUS ST. JOHN ST. MAARTEN ST. MARTIN ST. THOMAS SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TINIAN TOGO TOKELAU TONGA TORTOLA TRINIDAD AND TOBAGO TRUK TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNION ISLAND UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA, BOLIVARIAN REPUBLIC OF VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALES WALLIS AND FUTUNA WESTERN SAHARA YAP YEMEN ZAIRE ZAMBIA ZIMBABWE What is your English speaking capacity?: None Beginner Intermediate Fluent How can we best contact you during your stay in The Palm Beaches?: Email Mobile Phone List any personal medical conditions/allergiesIf none, please write NONE: Emergency Contact Emergency Contact Name: Relationship to you: Mobile Phone: Media Outlet / Publication Media Outlet / Company you will be writing for: Description: Medium: Broadcast Print Publication Radio Social Media Digital Publication Print Circulation/Reach: Readership: Trade Consumer Target Audience: Please describe your audience/readership in detail. If available, please link to publication media kit or readership statistics Audience Demographics: Reader Median HHI: Region of distribution: Media Outlet website: Assignment Details What is your story focus?: If Other - Please Specify: Expected Story Placement Date: Letter of Assignment: udf_213 Yes No Assigning Editor (Name, position, email): What is anticipated length of coverage for The Palm BeachesPlease note in pages and word count.: Images included? Requested experiences as part of your story: Adventure / Water sports Budget Friendly Dining Beaches & Parks Family Friendly History Luxury Nightlife Romance / Weddings Shopping Spa/Wellness Golf Arts/Culture Other (see below) Activity preference: --None-- Both Indoor & Outdoor Attractions Outdoor Attractions Indoor Attractions Published Articles Please include links to at least three of your bylined articles that have been published within the last two years. 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How will you be arriving to The Palm Beaches?: Flying Driving Other (add details below) Other Arrival Details: Which airport will you be flying in to?: Palm Beach International Airport (PBI) Fort Lauderdale International Airport (FLL) Miami International Airport (MIA) Southwest Florida International Airport (RSW) Orlando International Airport (MCO) Will you require ground transportation assistance during your visit?: Would you rather experience more planned activities or leisure time?: --None-- Planned activities Leisure time Have you made any independent arrangements we should be aware of?: Is there anything else you would like toshare with us?: Terms and Conditions I am agreeing to receive email communication from DTPB.: contact_sendemail Yes No I understand that by clicking I am agreeing to DTPB's Privacy PolicyBy completing this form, you may receive future emails from DTPB. I acknowledge that I have reviewed the EU GDPR information Verification: * Required. Submit Reset