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: [email protected]

All entries should be clearly marked Real Life Matters