Media Accreditation Registration Form: WSIS-II Tunis 2005

MEDIA ACCREDITATION FORM

PrepCom 3 Tunis Phase,
19 - 30 September 2005
Palais des Nations, Geneva, Switzerland

To be completed after reading the accreditation procedure available here

* = Mandatory

PERSONAL DETAILS

Mr Ms

* Family Name:

* First Name:

*Job Title:

* PERSONAL CONTACT DETAILS¹ A minimum of 1 of the following 4 fields is required.

Telephone:	Country	Area	Number

Mobile:	Country	Area	Number

Fax:	Country	Area	Number

e-Mail:

PUBLICATION / MEDIA DETAILS

* Name of Media (Publication / Radio / TV station / Press Agency)

* Country of
Parent Company:

PUBLICATION / MEDIA CONTACT DETAILS¹

* Address of Media (Publication / Radio / TV station / Press Agency)

* Postal Code:
* City:
* Country:
URL of Media:
Address where documentation should be sent, if different from the address of Media given above

* MEDIA CATEGORY

Daily press
	General Correspondent
	Technology Correspondent
	Business Correspondent

	Trade Press
	Economic/Business Press
	On-Line Publication
	Press Agency

Audiovisual press
	TV Station
	Radio Station
	Press Photographer

FAST TRACK ACCREDITATION DETAILS

I am accredited at the United Nations in

New York

Geneva

Nairobi

Vienna

¹ ITU publishes the information provided on this form on the WSIS website. If you do not wish your contact details to appear, please tick this box

Note: By default accredited media are placed on the ITU media information mailing list. Should you not wish to continue to receive ITU media information releases after this event please check the following box.

ATTENDANCE DATES

Date of arrival

Date of departure