REQUEST FOR ACCREDITATION OF MEDIA REPRESENTATIVE
PERSONAL DATA
1. Name
(Family name)
(First name)
2. Place and date of birth
3.Nationality
4.Passport No.
5.Permanent office address
Telephone
Fax
DATA ON THE MEDIA ORGANIZATION YOU REPRESENT
6. Name of organization
7. Contact person and title
8. Headquarters' mailing address
Telephone
Fax
9. Status/Ownership:
Educational/Public
Government/state
Private
Specify
10. Type of medium
(Check as many as necessary)
:
Daily newspaper
Photo/visual service
Television
News agency/service
Radio
Weekly pubblication
Other
Specify
11. Position:
Cameraperson
Director
Photographer
Reporter
Correspondent
Editor
Producer
Technician
Other Specify
12. Working language(s) of your media organization
13. Your main news topic(s) or field(s) of coverage
(if applicable)
14. For contact during conference
Address
Telephone
Fax
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