AFA09 Media Accreditation Form

Personal Information
Salutation * Mr. Ms. Mrs.
Name * First Last
Phone (country.area.number)

Please provide at least one contact number.
Mobile (country.area.number)

Please provide at least one contact number.
Fax (country.area.number)
Email *
Citizenship *
Date of Birth * / MM / DD YYYY
Place and country of birth *
Permanent Address
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Media Organization
Name of Organization
Web URL
Organization (Headquarters) Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Local Address (if applicable)
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Type of Medium (choose one only) News Agency Photo TV Daily Paper Radio Magazines Online Media
Other medium, please specify:
Your Position (choose one only) Reporter Producer Technician Correspondent Cameraman Photographer Freelance Journalist Journalist
Other position, please specify: