Media Registration Form

Publication Details
Publication Name :
Address :
City/State :
Postal Code :
Country :
Telephone Number :
Fax Number :
Email :
Type of Publication
Frequency of Publication
:
Circulation Print Run :
Countries Covered :
Years in Circulation :
Media Profile
(target markets, key
features in the
publication, etc.)
:

Media Delegate Details
Family Name :
Given Name :
Email :
Position in Organisation :
Name to Appear on Badge :
Accommodation Required :
Yes No

Agreed Media Coverage Detail
Please state how you will cover this event. :
Please state the name(s)
of the person(s) you intend
to interview in your
coverage of this event.
:
Please state the language
medium of the report you
will produce, the length of
your report, and the relevant
segment in which the
report will be featured
in your publication.
:
Please state the issue of
your publication title
that this media coverage
will appear in.
:


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