GOVERNMENT OF MEGHALAYA DIRECTORATE OF INFORMATION AND PUBLIC RELATIONS APPLICATION FORM FOR ACCREDITATION CATEGORY FOR WHICH APPLIED CORRESPONDENT EDITOR-CUM CAMERA CORRESPONDENT PERSON PERSONAL DATA 1. Name of the journa list: ________________________________________________________ (In Block Letters) 2. Father's/Mother's/Husband's Name: ______________________________________________ 3. Date of Birth: ________________________________________________________________ 4. Place of Birth: ________________________________________________________________ 5. Nationality: __________________________________________________________________ 6. Office Address: _____________________________________________________________ Telephone No. __________________ Fax No. _____________________ E-Mail Address ___________________________________________________ 7. Present Residential Address: ____________________________________________________ Telephone No._________________ Cell Phone No. _______________ 8. Permanent Address: ___________________________________________________________ 9. Places of Stay during last five years 10. Emoluments/Salary per month: __________________________________________________ (attach certificate) 11. Present designation in the Organisation: ___________________________________________ ___________________________________________________________________________ 12. Whether employed full time: ____________________________________________________ Sl. Period of Stay Address District State No. From To 1. 2. 3. or part time? Contt..2../ -2 13. Are you engaged in any other works?: ____________________________________________ (Please give details) 14. Educational & Other: __________________________________________________________ Qualification. 15. Professional experience: 16. Have you at any time been accredited: _____________________________________________ with any Government. If so, mention the period of accrediattion. Sl. No. Period of Stay Name of the Post held News Media Organisation where served as journalist Salary From To 1. 2. 3. 4. 5. I promise that I will not engage myself in any work other than journalistic. I also promise to surrender my accreditation card within 15 days of my ceasing to be the Editor/Correspondent/Cameraperson of the organisation, on whose behalf I am being given accreditation. Signature of the applicant. CERTIFICATE FROM EDITOR/MANAGER Certify that Shri/Smti _______________________________________________________is a Correspondent of ____________________________________________________. She/He requires an Accreditation/Correspondent Identity Card to meet and attend official functions to discharge his/her duties on behalf of the Newspaper/News Agency. Certified that Shri/Smti _______________________________________________________ is working in this Organisation since _________________________________________________. Place : Date : Signature of the Editor (Office Seal) News Agency/Photo Agency/News Feature Agency 1. Name of the Agency : _______________________________________ 2. Date of Establishment : _______________________________________ 3. Frequency of distribution of news/photo/feature : _______________________________________ 4. Method of distribution 5. Number of subscribes 6. Details of subjects covered 7. Annual revenue earned during the last financial year 8. Number of Correspondent/Cameraperson accerdited at present 9. Any other information : _______________________________________ : _______________________________________ : _______________________________________ : _______________________________________ : _______________________________________ : _______________________________________ I hereby certify that the information given in the application form is correct. I also undertake that I will inform the D.I.P.R. within a period of 15 days of his/her casing to be correspondent/cameraperson etc. in our media organisation and his/her Accreditation card will be returned to the D.I.P.R. immediately. Date: _______________ Signature of the Editor/Chief of the organisation ___________________ Name ___________________________________ Office Stamp:
