TAMIL DEVELOPMENT, RELIGIOUS ENDOWMENTS & INFORMATION DEPARTMENT GOVERNMENT OF TAMILNADU APPLICATION FOR PRESS ACCREDITATION ( to be submitted in duplicate) PART I Name of the Journalist : ( In Capital Letters) Mother / Father / Spouse Name : ( In Capital Letters) Category for which applied (Tick the appropriate Column ) : Editor Correspondent Reporter Photographer Editor cum Reporter Nature of Organisation : I News Agency providing news to (Tick the appropriate Column) Newspaper Magazines Radio Television Stations Others pl. specify. II. News Media (Tick the appropriate Column) Newspaper News Agency Feature/Photo Agency Broadcasting Television Date of Birth : Nationality : ___________________________________ Office Address : ___________________________________ ___________________________________ ___________________________________ Passport Size Photo Telephone No : Fax No : Cell No : E-Mail Address : ____________________________________ Present Residential Address : ____________________________________ ____________________________________ ____________________________________ Telephone No : Fax No : E-Mail I D : ____________________________________ Permanent Residential Address : ____________________________________ ____________________________________ ____________________________________ Salary (per month) : Full Time Part Time Nature of Employment : Are you engaged in any other work: _______________________________________ If so specify _______________________________________ Education & Other qualifications : _______________________________________ _______________________________________ Professional Experience : S.No Period of Service From To Designation News Media Organisation Salary P.M 1 2 3 4 Accd. No Year valid upto Have you ever been accredited with the Dept. of Information, Govt. of TN. : If so, mention in which Year you were accredited I promise that I will not engage myself in any other work activity other than journalism. I also promise to surrender my accreditation card within 15 days of my ceasing to be the Editor/Correspondent/Cameraperson of this organization, on whose behalf I am being given accreditation. Signature of the applicant Dated : Place :-PART II Form A : Newspapers ( In case of Newspaper fill A, for News Agencies fill B, for Electronic media fill C ) Name of the Newspaper / periodical : _____________________________ RNI Registration No : _____________________________ Language : _____________________________ Place / places of Publication : _____________________________ Size of the pages of Newspapers : _____________________________ Total No. of pages : _____________________________ Circulation as certified by RNI / ABC : ______________________________ (last year) Date of such certification : ______________________________ subjects covered in day wise : ______________________________ Status of the newspaper : ______________________________ No of issues published during the last 12 months. : ______________________________ Name of the Group / Chain. if any to which the newspaper belongs : ______________________________ If it is a Newspaper group / chain, please give details of the various publication of the Group : S.No Name of Publication Language Place of publication Circulation Signature of the Applicant PART II Form B : News Agencies Name of the Agency : ____________________________________ Date of Establishment : ____________________________________ Frequency of distribution : ____________________________________ No of Subscribers : ____________________________________ Details of Subjects covered : ____________________________________ Number of Correspondents : ____________________________________ Any other information : ____________________________________ Signature of the Applicant PART II Form C : Television News Production Organization Name of the Organization : ___________________________________ Address : ___________________________________ Dated of Commencement : ____________________________________ Headquarters of the Organization : ____________________________________ Schedule of the telecast of news / Current affairs programmes. : ____________________________________ Subject of particular focus by the media concerned : ____________________________________ Signature of the Applicant PART III CERTIFICATE BY EDITOR / CHIEF OF BUREAU (Applicable only in case of applications recommended for full time employees) I hereby certify that the information given in the application form is correct. I also certify that Thiru/Tmt. _______________________________ is on the pay-roll of our organization. I further state that I will inform to the department within a period of 15 days in case Thiru/Tmt. ___________________________ ceases to be correspondent/ cameraperson etc. in the employment of our organization and his / her accreditation card will be returned to Information department immediately. Signature of the Editor / Chief of Bureau Date : Name : Office seal : Part IV DOCUMENTS TO BE ATTACHED WITH APPLICATION FORM GENERAL REQUIREMENTS 1. Three recent stamp size photographs with name on the reverse. 2. Copies of appointment letters showing terms and conditions, post, salary, etc. issued by the present and previous employers in favour of the applicant. 3. Latest Salary slip/Certificate. 4. Copy of Service Certificate certifying the period of service of the applicant or a copy of relieving order issued by the previous employer. 5. Copies of certificates of educational and professional qualifications. OTHER DOCUMENTS REQUIRED: a) Newspaper/Periodicals Circulation Certificate issued by the RNI/ABC showing the latest circulation of the Newspaper/Periodical. Issues of the newspaper/periodical as under:- 1. Last six months Issues (In case of Daily Newspaper) b) News Agency/Photo News Agency/News Feature Agency Latest list of subscribers A Certificate from Chartered Accountant indicating the annual revenue of the agency earned during the last financial year. c) Electronic Media Balance sheet indicating annual revenue earned during the last financial year. Uplinking/telecast permission from the Ministry of I&B Govt. of India to ascertain the date of commencement of telecast. FACT SHEET For Office Use - Accreditation No: _____________ Valid Upto : ___________ Signature of the Applicant FACT SHEET 1 Name of the Applicant (Tamil) : (English) : 2 Designation : 3 Name of the Newspaper / Media : (Tamil) : 4 Office Address Pin code No : : a) Telephone No : b) Fax No. : c) E - mail : 5 Date of Birth and Age : 6 Residential Address Pin Code No : : ii) Telephone No : iii) Cell No : For Office Use only- Accreditation No Signature of the Applicant Date : Place : Passport Size Photo
