REPÚBLICA DEMOCRÁTICA DE TIMOR-LESTE MINISTÉRIO DA ADMINISTRAÇÃO ESTATAL Secretariado Técnico da Administração Eleitoral Rua de Caicoli, Díli, Timor-Leste T. +670 3317445 / 3331174 - Email: timorstae@gmail.com
International Media Acreditation Form EARLY NATIONAL PARLAMENT ELECTION 2018 To be submited until 4 May 2018
Organization
a)
Organization responsible
b)
Adress of the organization
c)
Name Name Street and number Zip-Code
City
State
Country
Telephone number Email Website
Coordinator
d)
Name Telephone number Email
Type of Organization
e)
News Agency TV Newspapper Radio Other If you chose [other] please specify
f)
Total number of journalist to be accreditd
I hereby confirm that the information provided is correct. I understand that if the present information is not correct, I will be sanctioned. Signature ot the responsible of the Organization
To be filled only by STAE officer g)
Received by Signature
Day
Month
Year
Day
Month
Year
Important Please submit present form with the following attachments to STAE 1. One (1) copy of the passport of each applicant to be accredited; 2. Two (2) color photos, size 3x4: 1 glue at the form and 1 with the name of the applicant on the back. Instructions to fill the Accreditation form a) Name of Organization to be accredited: to write the name of the Organization to be accredited to follow Early Election 2018; b) Organization responsible: name of the person who is the responsible for the organization mentioned at a); c) Address of the organization: where is physically located the mentioned organization; d) Coordinator: name of the person which was selected to be the coordinator of the Team; e) Type of the Organization: to select one (1) option. If it is not none of this options, please select others and describe the type of organization; f)
Total jornalist to be accredited: to write the specific total number of journalists to be accredited by the mentioned Organization;
g) To be filled only by STAE officer: to be filled by the STAE officer accreditation (name, date and signature);
that is receiving the
h) Name of the Organization: to write the name of the organization that will submit the applicant to be accredited to observe Early Election 2018; i)
Photo: 1 photo to be glued at the passport of the respective applicant’s name;
j)
Applicant: to write the name of the journalist to be accredited to follow the Early Election 2018;
k) Passport: Number and validiti expiry of the passport of the respective applicant; l)
Contacts: the contacts of journalist;
m) Signature of the journalist: the applicant to sign.
REPÚBLICA DEMOCRÁTICA DE TIMOR-LESTE MINISTÉRIO DA ADMINISTRAÇÃO ESTATAL Secretariado Técnico da Administração Eleitoral Rua de Caicoli, Díli, Timor-Leste T. +670 3317445 / 3331174 - Email: timorstae@gmail.com
International Journalist - Accreditation Form E A R LY N AT I O N A L PA R L A M E N T E L E C T I O N 2 0 1 8
Name
Organization
h)
Photo i)
3X4
Name
Applicant
j)
Male
Country
Nationality
Gender
Number
Passport
k)
Contacts
l)
Telephone number
Signature ot the Journalist
m)
Female
Day
Month
Year
Day
Month
Year
Date of Birth
Date of Expiry