Form pendaftaran meliput WCRC dari Kementerian Luar Negeri

Media registration will close on 10 May 2014 at 01.00 pm Jakarta time.

Incomplete and late applications will not be processed.

First Name

Last Name 

Name on Badge

Date and Place of Birth:

Sex:

Nationality:

ID/Passport No. :

Expiry Date:

Issued at:

E-mail address :

Mobile number (Country code – phone number):

Name of Media :

Type of Media:

[    ]  Newspaper 

[    ]  News Agency 

[    ]  Radio 

[    ]  Television

[    ]  Photo Agency 

[    ]  Online Media

[    ]  Other (specify)

………………………………….

Country of Head Office:

Office Address (may differ from your head office):

 Tel No.: 

 Fax No.:

Your position in agency :

[     ]Reporter    [    ]Cameraman    [    ] Photographer

[     ] Technician   [     ]Correspondent      [    ] Freelance      

[     ] Others (please specify)______________________

Origin of Media:

[   ] Indonesian Media                

[   ] Jakarta Based Foreign Media

[   ] Visiting Foreign Media

Domicile Address in Indonesia : 

ACREDITATION REQUIREMENT

Completed registration form.

Letter of assignment from the editor/executive of the media

A recent digital passport-sized photograph (minimal resolution 480 x 640)

Copy of  valid Passport for Non-Indonesian applicants and KTP for Indonesian applicants.

Please attached accreditation requirementsand send an email to:

wcrc2014.media@gmail.com

I HEREBY CERTIFY ALL ABOVE INFORMATION ARE TRUE AND CORRECT

___________________________________

Applicant’s Signature