APPLICATION FORM FOR ACCREDITATION OF JOURNALIST/ PRESS CORRESPONDENT/ CAMERAMAN TO THE GOVERNMENT OF MANIPUR (To be filled in triplicate) (See Rule No. 11 and 12) From the Editor: ............................. Name of Journal/ News Agency: ........................ Address: ................................ To, The Director, Information & Public Relations, Government of Manipur, Imphal. Sir, The Journal/ Correspondent/ Cameramen/ News Reel of .............. ......................... (Name of Journal/ News Agency/ Photo Service) whose name and particulars are appended herewith may kindly be granted accreditation to the Manipur Government and allowed the usual press facilities. 1. Name of the Journal/ News Agency/ Photo Agency (IN BLOCK LETTER) : 2. Address of the Journal/ News Agency/ Photo Agency : 3. Frequency of publication in case of journal, method of distribution services centre or newspapers catered for in case of News agencies : 4. Audited circulation in case of Journal : (Copy of certificate to enclosed) 5. Special feature of the Journal/ News Agency (If any) : 6. Date and year of first publication of the Newspaper journal and Registration No. of the Registrar of Newspaper for India : 7. Period of ceasation of publication of the Newspaper/Journal and the reason thereof : 8. Particulars of the Journalist/ Correspondent desired to be Accredited : i. Name in full : (IN BLOCK LETTER) ii. Date of birth : iii. Father's Name : Contd/ -2 - 2 iv. Permanent Address : v. Post Office : vi. Present Address : vii. Experience in journalism, Name of Newspaper/ News Agencies served, position held and duration of service in each: (Document to be enclosed) viii. Details of Accreditation Cards awarded by Govt. of India/State Govt. previously, if any. State the No. and date of issue. If surrendered or cancelled, the reason thereof. : I certify that the Journalist/ Correspondent is a full time professional Journalist and he will be in the State Headquarter/District Headquarters of Manipur during the period of accreditation. I have explained "The Rules for Accreditation to the Government of Manipur of Press Representatives representing Newspapers and he/she has agreed to abide by these rules. The above statements are correct to the best of my knowledge and belief. Date: ....... Signature: ............... Place: ....... Editor/ Employer: ....................... Newspaper/ Agency: ............ (WITH SEAL) Enclosure :- 2 (two) copies of the latest Stamp size Photographs. .........
