P

REGISTRATION FORM 
FOR THE MEDIA			

SURNAME:      
NAME:      
DATE AND PLACE OF BIRTH:      
NATIONALITY:      
PASSPORT NUMBER:      			Date and place of issue:      
EXPIRY DATE:      
MEDIA OUTLET:	     
COUNTRY OF HEAD OFFICE:      
OFFICE ADDRESS:	     
OFFICE TELEPHONE:      
FAX:      
MOBILE NUMBER:	      
EMAIL:      
TYPE OF MEDIA:  News Agency 	Print Press 	TV 	   Radio 
Online  	other   please specify      
FUNCTION:	Journalist  	Photo journalist  		Camera  	Technician 
PRESS CARD NUMBER:       
ISSUED BY:      
DATE OF ISSUE:       
DATE:	      					SIGNATURE:      
Please kindly return the completed form and the colour picture not later than October 30TH, 2007 to osce.madrid.accred@maec.es