Accreditation request form for
Foreign Ministers meeting, 
New York, 21 September 2006
	Particulars
	Title:	Mr.                Mrs.   
	First Name:	
	
	Last Name:	
		
	Nationality:
	Date of Birth:	           (day)              (month)                 (year)
	
	Place of Birth:
	
	Country of Birth:
	
	Passport/ID Card 
	
	Issued by:
	
	Press Card Nr:
	
	Issued by:

		Media Info
	Qualification:	Journalist     	Producer      	Cameraman
		
		Photographer	Technician	Other:	

	Type of Media:	News Agency	Newspaper	Magazine

		Television	Radio	Photo Agency		
	Media 	
	Home country of media organisation:    

		Address and Communication Info

		Office telephone no. +	                                      Office Fax:   +
	
	Mobile phone no.  +  	                                          E-mail:

	Street Name + House no.:	 
	City Postal Code:                            City: 
	
	Country: