MEDIA REGISTRATION FORM

Workshop on the Regional Implementation of the

United Nations Global Counter-Terrorism Strategy in South East Asia
3-5 November 2010, Ayodya Resort Bali
Nusa Dua, Bali
Indonesia

Personal Data

1. Name: ________________________________,______________________________________
(family name) (first and middle name)
2. Place and date of birth: __________________,_____________________________________
3. Nationality: ________________________ 4. Passport number: _______________________
5. Permanent office address (if different from your organization's headquarters):
_________________________________________ telephone: _______________________
_________________________________________ e-mail: __________________________
___________________________________________________________________________________
6. For contact during conference:
address: ___________________________________ telephone: _______________________
___________________________________ e-mail: __________________________
___________________________________________________________________________________
Data on the media organization you represent

7. Name of organization: ________________________________________________________

8. Contact person and titel: ______________________________________________________
9. Headquarters' mailing address: ______________________ telephone: ________________
e-mail: ___________________
10. Type of medium (check as many as necessary):
( ) daily newspaper ( ) photo/visual service ( ) television
( ) news agency/service ( ) radio ( ) weekly publication
( ) other (specify):
11. Position:
( ) cameraperson ( ) director ( ) photographer ( ) reporter
( ) correspondent ( ) editor ( ) producer ( ) technician
12. Working language(s) of your media organization: _______________________

13. Signature

( )

Note: Please fill in the form. After completion, please scan and send your valid Press ID, passport, visa
and one (1) color photo (4x6cm), and send it to: accreditation.media@unic-jakarta.org and copied to
accreditation.media@gmail.com or fax to Media Accreditation (+6221) 3983 1014.
Note: file should not exceed more than 320 KB.

NOTE: KINDLY DUPLICATE THIS FORM IF YOU NEED TO

For details please contact: Mr. Adila Arief at +628111 891 736