Media Accreditation Form

DOC No:......

ID PHOTO

75^th ORDINARY SESSION OF THE OAU COUNCIL OF MINISTERS

AND THE 38^th SESSION OF THE ASSEMBLY OF HEADS OF STATE AND GOVERNMENT

DURBAN, SOUTH AFRICA, JULY 2002

MEDIA ACCREDITATION FORM

(Please type or print in block capitals)

Title Family Name First Names

........... ................................................... ...............................................................

Date of Birth: ..................................................... Nationality: ...............................................

Passport Number: ................................................................................................................................

Name and Address of Organisation Contact Address

............................................................. ..................................................................................

Cellular Tel: .......................................... Press Card (0r equivalent ID) number and issuer:

Tel: .......................................... .................................................................................

Fax: .......................................... Email: ........................................................................

Type of News Organisation (please indicate √ )

ڤ Newspaper ڤ Magazine ڤ TV ڤ Wire Service ڤ Radio ڤ Photo Agency

Function

ڤ Correspondent ڤ Radio Reporter ڤ Photographer ڤ TV Cameraperson

ڤ TV Reporter ڤ Technician ڤ Other (please specify)........................................................................

I, .................................................................... hereby confirm that the information disclosed herein is correct.

....................................................... ......../ ......../ 2002 ....................................................

APPLICANT DATE PLACE

NB: Please include an original letter of authorisation from your editor or producer on your organisation's stationery. Your application will not be processed without this.

FOR OFFICIAL USE ONLY

Letter from editor attached to request Y / N

Proof of journalist status provided Y / N .................................... .................................

MEDIA LIAISON OFFICER DATE

Send to: Department of Foreign Affairs Deliver to: Department of Foreign Affairs

The Director: Media OAU/AU Summit, The Director: Media OAU/AU Summit

For attention: Ms A Lombaard For attention: Ms A Lombaard

Private Bag X152, Pretoria, 0001 Room 298 Union Buildings, Pretoria