Print

MEDIA ACCREDITATION APPLICATION FORM


New name of Union Sep 2012

 

8th SESSION OF THE PUIC CONFERENCE AND RELATED MEETINGS

KHARTOUM – REPUBLIC OF THE SUDAN

17 – 22 JANUARY 2013

 

MEDIA ACCREDITATION APPLICATION FORM

 

Please fill in – using capital letters – and return this form no later than December, 2012, to both address:

       

 

THE NATIONAL LEGISLATURE

REPUBLIC OF THE SUDAN

PUIC GENERAL SECRETARIAT

Postal Code – 14416

Tel: (249) 187 557918 – 187 557959

Fax: (249) 187 560950

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

P.O. Box 19395 – 3851, Tehran, Iran

Tel: (9821) 22418860/ 61 / 62

Fax: (9821) 22418858/59

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

(   ) Sudan Media

(   ) International Media

(   ) Official Media Delegation

Status

o   Reporter

o   Photographer

o   Videographer

o   Other, …………

Other information you may want to add

Name

First Name:

Middle Name:

Family Name:

Office Detail

Name of Head Office:

Press Card:

Head Office Address:

Expire Date:

Telephone:

Website Head Office:

Email:

 

Office In Sudan

 

Personal Data

Please check type of Media organization you represent:

(   ) Daily Media

(   ) Magazine

(   ) News Agency

(   ) Radio

(   ) Television

(   ) Photo Agency

(   ) Documentary

(   ) Other (specify)

 

      ……………………..

Country of Origin:

Passport No:

Nationality:

Issued at:

Citizenship:

Expire Date:

Birth Date:

Length of Stay:

Birth Place:

Email:

Sex:   (   ) Male    (   ) Female

Accreditation Requirements:

1.    Accreditation form properly fills in.

2.    Letter of request from respective agencies.

3.    Photo.

4.    Photocopy of Press ID.

5.    Photocopy of Passport.

Telephone:

Mobile Phone:

Contact Person in Emergency:

 

 

 

 

 

I Hereby Certify all above Information are true and correct

 

Signature: