(To be enclosed with the Covering Letter on Letter Head) Name of the PvT. Electronic Media: Language : Address : PASSPORT SIZE PHOTO TO BE PASTED HERE ( ANOTHER PHOTO TO BE PINNED AT THE RIGHT CORNER OF THE APPLICATION) Office Telephone No. : E-Mail Address Date of commencement Name of the Editor Whether Telecasting news (or) not No. of Media Units working in A. P. Linkage of the Media Unit Whether programmes are being Up-linked regularly : : : : : : : Fax No. : PERSONAL INFO: Name of the Applicant Designation Nature of duties being attended Residential Address : : : : Telephone Nos. Off. : Res. Mobile: E.Mail Address: Whether accreditated earlier (Yes/No) : If accreditated, when : Latest Accreditation Card No.& year : Experience in detail : (proof Certificate shall be enclosed) Management/ Period Total Media Name From To years Date of joining in present management: (Any Additional information may be annexed) (Signature of the Applicant) Editor's Recommendation ...................................................................................................................................................................................................... ...................................................................................................................................................................................................... ...................................................................................................................................................................................................... Office Seal Signature (with stamp) APPLICATION FORM FOR NEWS / PHOTO AGENCY ACCREDITATION FOR 200 200(To be enclosed with the Covering Letter on Letter Head) Name of the News / Photo Agency : Language : Date of commencement : Address : PASSPORT SIZE PHOTO TO BE PASTED HERE ( ANOTHER PHOTO TO BE PINNED AT THE RIGHT CORNER OF THE APPLICATION) Office Telephone No. E-Mail Address : : Fax No. : Agency Registration No. & Date (Under Shops and Establishment Act. Certificate copy to be enclosed) Latest renewal No. & Date Renewal validity date (Certificate copy to be enclosed) NO. of Paying Subscribers & their details : : : : Name of the Editor : No. of Reporters working : Details of other employees : No. of average News items / Photographs published per month (latest 3 months press clippings to be enclosed) Mode of Dispatch : : Telephone / Teleprinter / Fax / E.mail / Cycle Messenger Annual Income of the last year from the Journalistic activity (C.A. Certificate to be enclosed) PERSONAL INFO: Name of the Applicant Designation Nature of duties being attended Residential Address : : : : : Telephone Nos. Off. : Res.: Mobile: E.Mail: Whether accreditated earlier (Yes/No) : If accreditated, when : Latest Accreditation Card No.& year : Experience in detail (proof Certificate shall be enclosed) : __________________________________________ Management/ Period Total Media Name From To Year a Date of joining in present management: (Any Additional information may be annexed) (Signature of the Applicant) Editor's Recommendation ...................................................................................................................................................................................................... ...................................................................................................................................................................................................... Office Seal Signature (with stamp) (To be enclosed with the Covering Letter on Letter Head) Name of the News Daily/Periodical: Language : Whether having own News Agency: YES / NO If yes, Name of the Agency : Address : PASSPORT SIZE PHOTO TO BE PASTED HERE ( ANOTHER PHOTO TO BE PINNED AT THE RIGHT CORNER OF THE APPLICATION) Office Telephone No. : E. Mail Address : Fax No. : R.N.I. Number (Copy to be enclosed) : Date of Commencement : Size of the News Daily / Periodical : No. of Pages : Periodicity : Name of the Editor : Details of Publication Centres : Circulation (At State Hqrs.) Circulation (In A. P.) (ABC/RNI latest circulation certificate to be enclosed) PERSONAL INFO: Name of the Applicant : : : Designation : Nature of duties being attended : Residential Address : Telephone Nos. Off. : Res. : Mobile: E.Mail Address: Whether accreditated earlier (Yes/No) : If accreditated, when : Latest Accreditation Card No.& year : Experience in detail : (proof Certificate shall be enclosed) ___________________________________________ Management/ Period Total Media Name From To years Date of joining in present management: (Any Additional information may be annexed) (Signature of the Applicant) Editor's Recommendation ...................................................................................................................................................................................................... ...................................................................................................................................................................................................... ...................................................................................................................................................................................................... Office Seal Signature (with stamp) APPLICATION FORM FOR FREELANCER ACCREDITATION FOR 200 200-. (To be enclosed with the Covering Letter on Letter Head) Name of the Applicant : Whether applying for the Accreditation of Freelance Correspondent / Photographer / Cartoonist : Address : PASSPORT SIZE PHOTO TO BE PASTED HERE ( ANOTHER PHOTO TO BE PINNED AT THE RIGHT CORNER OF THE APPLICATION) Office Telephone No. : Fax No. : E. Mail Address : Whether accreditated earlier (Yes/No) : If accreditated, when : Latest Accreditation Card No.& year : Experience in Journalism Profession: (Proof Certificate(s) shall be enclosed) ___________________________________________ Management/ Period Total Media Name From To years ___________________________________________ For Freelance Correspondent Accreditation: (Not less than 6 latest published articles with byline in Big & Medium dailies / Magazines in the year preceding to the date of Application shall be enclosed). For Photographer/Cartoonist Accreditation: (Photo/Cartoon clippings published in different daily newspapers / periodicals for a period of (3) months prior to the date of application for accreditation along with a certificate to the effect of publication from the respective organizationshal be enclosed). Any additional information may be annexed: (Signature of the Applicant) APPLICATION FORM FOR OFFICIAL MEDIA ACCREDITATION FOR 200 200 (To be enclosed with the Covering Letter on Letter Head) Name Of The Media Uniit : Name & Design. Of The Office Head: Office Address : PASSPORT SIZE PHOTO TO BE PASTED HERE ( ANOTHER PHOTO TO BE PINNED AT THE RIGHT CORNER OF THE APPLICATION) Office Telephone No. : Fax No. : E. Mail Address : PROFESSIONAL INFO: Name of the Applicant : Designation : Nature of Duties being attended : Residential Address : Telephone Nos. Off. : Mobile : E. Mail Addres : Res. : Whether accreditated earlier (Yes / No): If accreditated, when : Latest Accreditation Card No.& year : Service in Media Related Job : Date of joining in present assignment: (Any Additional information may be annexed). Head of the Office Recommendation (Signature of the Applicant) ...................................................................................................................................................................................................... ...................................................................................................................................................................................................... ...................................................................................................................................................................................................... Office Seal Signature (with stamp)
