FRESH APPLICATION FORM FOR PRESS IDENTITY CARD FOR JOURNALIST OF PRINT/ ELECTRONIC MEDIA 1. Name in full (BLOCK LETTERS) : ........................ 2. Father's/ Husband's name : ..................... 3. Address : .................. ................... 4. Date of Birth : .................. 5. Educational Qualification : .................. 6. Other qualification/ professional qualification : .................. 7. Designation/ position held : .................. 8. Name of other Organization : .................. 9. Telephone No. : .................. 10. Identification Mark : .................. ................... I hereby declare that the above particulars are true to the best of my knowledge and belief. Date: Signature of Applicant (TO BE FILLED UP BY THE PUBLISHER/ EDITOR/ PRODUCER/ MANAGER) I hereby certify that Shri/Smt/Km .................... ............ S/O, W/O, D/O .................. has been working in my organization as .................... under my supervision since ............. . I have no doubt in his/her conduct and integrity. Further, I take full responsibility for strict compliance of the relevant provision laid down in the guidelines for issuing Press Identity Card in respect of Shri/Smt/Km......................... Contd/. -2 - 2 - The details of my Media organization are given below 1. Name of Paper/Organization : .................. 2. Office Address : .................. 3. Full Name of Editor : .................. 4. Full Name of Publisher : .................. 5. Full Name of Producer : .................. 6. Full Name of Manager : .................. 7. R.N.I. No. : .................. 8. Affiliation if any (to be supported by documents) : .................. 9. P & T Registration No. : .................. 10. Latest audited circulation figure : .................. 11. Date of first publication/ production : .................. 12. Name of other DIPR Press Identity Card holders:-Name Designation I/Card No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Signature Publisher/ Editor/ Producer/ Manager (with date & seal) N.B. a) Please strike out whichever is not applicable. b) Enclosed 2 (two) stamp size photographs. c) Enclosed appointment order.
