Media Request Form 

The Wisconsin Tobacco Prevention and Control Program is offering existing media resources to Wisconsin organizations and partners. These resources are available on a limited basis. If you are interested in applying to use resources from the Media Resource Center, please fill out the form below. Once your information has been reviewed, we will contact you to discuss the details of your proposal.

Please note that this site provides only the produced media materials and resources. The costs of buying time, printing, or distributing these materials is the responsibility of the organizations or individuals requesting the materials.

If you have any questions about the Media Resource Center, please contact Spencer Straub at 608-267-0944 or strausl@dhfs.state.wi.us.

* All fields are required
* Please fill out a separate form for each piece of requested media

Organization Requesting Materials

Lead Contact

Address

City State Zip

Phone Fax

Email

What material would you like to request?

What is the purpose of the advertising/marketing?

What is your target population?

If possible, would you like to modify materials?

What specific media outlets will you use?

What is your timeframe for use?