Accreditation form for atlantic council-pism global forum data of the editorial office



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ACCREDITATION FORM FOR ATLANTIC COUNCIL-PISM GLOBAL FORUM


DATA OF THE EDITORIAL OFFICE

name




address




telephone




e-mail




website




contact person




DATA OF ACCREDITED MEDIA REPRESENTATIVE

media representative #1

name and surname




date of birth




nationality




passport number (for non-Polish citizens) *




PESEL number and a father’s name (for Polish citizens) *




official ID card number (for polish citizens)




passport/ID Expiration DATE




e-mail address




Telephone number




TITLE (please select one)

journalist

cameraman

photojournalist

vehicle information

car pass (please select one)**

requested / not requested

car registration number







type of media (please highlight all applicable)

press

radio

television

internet portal

please add any additional information below:


* data required by Biuro Ochrony Rządu (BOR) – the Government Protection Bureau



** for outside broadcast vans
COMMENTS:

  1. Accreditation applications will be accepted until July 4, 2017.

  2. Please send this form by e-mail to Nicole Hobbs at nhobbs@atlanticcouncil.org and Tomasz Sikorski at t.sikorski@unitedpr.pl.

  3. The accreditations granted shall be issued on the basis of a valid official ID card.


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