RENEWAL FORM FOR PRESS IDENTITY CARD 1. Name of Journalist: ....................................................... (in BLOCK LETTERS) 2. Father's/ Husband's name: ......................... 3. Address: .............................. 4. Telephone No.: ............................ 5. Designation: ............................. 6. Press Identity card No.: ......... Date of expiry......... 7. Name of Newspaper/ Agency: ...................... 8. Latest audited circulation figure: ..................... 9. Identification Mark: ............................. 10. Blood group: ............................... Dated ......... Signature of Applicant I Certify that Shri/Smt/Km ......................... joined the Newspaper/ Media Agency .................... and is still working as ............................. Dated ...... Signature ................ Name................ Editor/ Manager/ Publisher (WITH SEAL) NOTE: 1. Any change/ transfer of press Identity card should be intimated to the concerned authority immediately. 2. Possession beyond validity date and unauthorized possession is punishable by law. 3. Press Identity card is subject to cancellation if not renewed in time. 4. Enclosed 2 (two) STAMP SIZE PHOTOGRAPHS. *******/ / / *******
