MEDIA ACCREDITATION
APPLICATION FORM

NAME  :  
ORGANIZATION  :  
POSITION  :  

ٱ Reporter    ٱ Photographer      ٱ Technician
ٱ Other (please specify) ………………………..

BUSINESS ADDRESS :  
ADDRESS DURING
CONFERENCE
:  
PLACE /DATE OF BIRTH :  
PASSPORT NO :  
NATIONALITY  :  
PRESS CARD NO  :  
ISSUING AUTHORITY :  

Enclose a letter of assignment from Editor/Executive of Organization and two current color photographs (3 x 4 cm) and return to the Media Secretariat no later than June 18, 2004. Foreign media: A journalist visa is required to cover the conference.  Please contact the nearest Indonesian Embassy/Representative Office (www.deplu.go.id)

For  further  information  please contact the Directorate for Information & Media Services, Department of Foreign Affairs of the Republic of Indonesia  through  Mr. Henry Kaitjily  at  phone: 62-8129516070; 62-21-3813453 ext. 4519, 3440488; fax:62-21-3857316 or e-mail to fasmedia@deplu.go.id or Mr. Arsi Dwinugra Firdausy at  phone: 62-8161131820; 62-21-3813453 ext. 4520