EVENT	Title:

Date:

Place:

Type of event :

Workshop /Conference /Symposium /Seminar

Media Briefing

Other:

(please specify):

MEDIA Registration Form
1. PERSONAL INFORMATION	Salutation : Mr. Mrs.

First Name:

Family Name:

Citizenship:

Date of birth (DD/MM/YY) :

Tel: Fax: Email:

2. MEDIA ORGANIZATION

Name:

HQ. Address:

Web address : http://

Country:

Local Address :

Web address : http://

Tel: Fax: Email:

3. TYPE OF MEDIUM

(check only one)

News Agency	TV	TV/Radio

Daily Paper	Photo	Internet

Other:

(please specify):

4. POSITION

(check only one)

Reporter	Producer	Technician

Correspondent	Editor	Photographer

Director	Cameraman
Other

(please specify):

5. PRESS CARD NUMBER

Number:

Issued by:
This form must be filled out in all its parts sent to :
Rosanna Santesso, Assistant Information Officer IKM by fax +39 041 528 99 95 or by electronic mail to r.santesso@unesco.org in copy to veniceoffice-event@unesco.org.

Accredited journalists will receive a badge upon presentation of their press card

Palazzo Zorzi – Castello 4930

30122 Venice, Italy

Tel. : +39 041 260 15 11

Fax : +39 041 528 99 95

www.unesco.org/venice

Le Directeur général

g_torre

2010-02-24

a_ajoux

Unesco