APPLICATION FORM FOR MEDIAPERSONS SEEKING ACCREDITATION

# Marked Fields are Optional

PERSONAL DETAILS
Applicant's Name :
Father's Name :
Date of Birth :    
Gender :
Email Address :
 Mobile Number :
Land Line No. with STD code(Office): #
Land Line No. with STD code(Residence): #  
PRESENT ADDRESS
Address :
City / Town / Village :
District :
State :
Pin Code :
PERMANENT ADDRESS
Click here if same as present address :
Address :
City / Town / Village :
District :
State :
Pin Code :
ORGANISATION DETAILS
Media Type :
Name of News Organisation :
Name of the Editor-in-Chief/Editor/Managing Editor/Resident Editor/News Editor/Appointing authority :
Mobile No. of the Editor-in-Chief/Editor/Managing Editor/Resident Editor/News Editor/Appointing authority :
Level for which apply :
Place of Publication (Newspaper)/Which Place where News Channel Operates(ElectronicMedia):
Place of Publication With Date:    
Periodicity :
Designation :
Place of Work :
 Place of Work (Since) :    
Annual Revenue of News Channel/Agencies/TV/Radio: (in amount)
Circulation in Haryana(in case of Newspaper):
Circulation(in case of Newspaper) : According to
VERIFICATION
Verified that the information provided under above columns is true and correct to the best of my knowledge and belief and nothing relevant has been concealed there from.

Security Pin
Enter security pin (case sensitive) :
Security Pin :