Real Life Matters Application Form

Please fill in the Application Form in English


Personal details</h2


Name:





Nationality:





Personal e-mail:





Home address:









Home telephone:





Home fax:





Position:





Professional experience

















Employer/media organisation



Name:





Address:









Telephone:





Telefax:





Email:





Publication, website, station or service where the entry was published/broadcast



Name:





Date published/broadcast: (Must have been published/broadcast between 1 November 2002 and 31 January 2004.)





Range and nature of the publication, website, station or service:










Category (Please tick one box)


( ) Print


( ) On-line


( ) Radio


( ) Television


Entry


Title of the entry:









Brief description of the entry and its impact:





















Declaration of the employer/commission company:



I confirm that ................................................ is a bona fide journalist and the work submitted is his/her own work. It does not owe its merit to sub-editing, rewrite or other production treatment.


Representative of company:

Contact phone:

Signature:

Date:


Declaration of entrant


I hereby:

- declare that this entry is my original work, apart from sub-editorial/production treatment;

- confirm that I have complied with all copyright requirements.


Signature of entrant:





Date:





Please send your entry to:



Real Life Matters

Att.: Ann-Christina Hansen

International Federation of Journalists

International Press Centre Résidence Palace

Second Floor, Bloc C

155, rue de la Loi

B-1040 Brussels

Belgium

Phone: +32 2 235 22 12

Fax: +32 2 235 22 19

E-mail: projects@ifj.org


All entries should be clearly marked Real Life Matters