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Personal Details
First Name:_________________________________
Gender:__________________________________
Middle Name:_______________________________
Date of Birth:______________________________
Last Name:_________________________________
Contact Details
Address Line 1: ______________________________
E-mail Address:______________________________
Mobile Phone:______________________________
City/State:___________________________________
Office Phone:_______________________________
Zip Code:___________________________________
Organization Details
Media Organization:____________________________
Editor/Manager Name:______________________________
Media Type:__________________________________
Editor/Manager E-mail:______________________________
Category :
Written Press
Editor/Manager Phone:_____________________________
Photographer
Outlet Address:____________________________________
Broadcast
Region of Circulation/Distribution:______________________
Application for:
Induction Ceremony Media Pass:________________
* Coverage of the induction ceremony may only include taking quotes, photos, and audio/video documentation of the event.
Date:_______________________________________________
As the Nominated Representative of the Applicant, I have shared the 2015 Asian Hall of Fame Media Pass Terms and
Conditions with the Applicant, who has read and agreed to these Terms and Conditions (following pages).
Name:____________________________ _ Phone:_____________________ E-Mail:___________________________________
Signature:_____________________________________
Date:_______________________________________________