WORLD SUMMIT ON SUSTAINABLE DEVELOPMENT

JOHANNESBURG, SOUTH AFRICA

23 August – 5 September 2002

 

APPLICATION FORM

DEADLINE FOR SUBMISSION: 22 APRIL 2002

 

Please type or use block letters.

 

Full name (as stated in passport):    

q            FEMALE

q            MALE

______________________________________________________________________________

[Title (Mr., Mrs., Ms., Dr.); first and other name; FAMILY NAME IN CAPITAL LETTERS]

 

Current position/job title ____________________________________________________________________

 

Media organization    _______________________________________________________________________

 

Media organization mailing address ____________________________________________________________

 

_________________________________________________________________________________________

 

Business telephone _____________________________  Home telephone _____________________________

 

Facsimile no. _________________________________    E-mail address ______________________________

 

Nearest airport ____________________________________________________________________________

 

Country of citizenship _______________________    City & country of birth ___________________________

 

Country of legal permanent residence __________________  Date  of birth ____________________________

                                                                                                                                            (month)           (day)           (year)

Best method and time of day to contact you ______________________________________________________

 

Years of experience as a journalist ­­­­­­­­­­­­­______

Years of experience covering population and/or environmental issues _________________

 

Publications/Productions and how often produced/distributed: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Type of Publication/Production:

q      Newspaper                           

q      Radio

q      TV          

q      Web

q      Other (please describe): ____________________________________________________________________________________________________________________________________________________________________

 

Estimated circulation: _________________________________________________________________________________________

 

Who is your primary audience? ________________________________________________________________

_________________________________________________________________________________________

NAME: __________________________________________

 

 

Possible story ideas leading to and resulting from the World Summit on Sustainable Development:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Reporting background (a paragraph outlining your reporting history, issues covered, areas of specialization, examples of stories that have had some impact, specifically with regard to population and environment issues):

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

How would you benefit from attending the WSSD?  What do you hope to accomplish through your participation? (Please fill out the attached form (page 3) with your answer, in 300 words or less.)

 

Please send two to three samples of your published work that illustrate your interest and/or reporting ability in population, health and environment issues.

Text Box: Editorial approval is a requirement for participation. Please have your editor review the following statement and have him/her sign it before submitting your application. I do hereby affirm that I am aware of this journalist’s application to attend the World Summit on Sustainable Development (WSSD), as sponsored by Population Reference Bureau (PRB). I understand that, if selected, this journalist will be attending the WSSD from 23 August through 5 September 2002. I also acknowledge that this journalist’s participation in the event is dependent upon our publication/production of this journalist’s pieces as developed in conjunction with WSSD events. Date ________________________ Signature of editor ______________________________________

 

Date ____________________ Signature of applicant ____________________________________________

 

Please submit your application to PRB via fax (202.328.3937, attn: Buffy Baumann) or email: bbaumann@prb.org.  If submitting by fax, please send an email notifying us of your intent to do so.

 

 

Population Reference Bureau

1875 Connecticut Ave. NW, Suite 520

Washington, DC 20009-5728

USA

Fax: 202.328.3937, Phone: 202.483.1100

Web: www.prb.org

WORLD SUMMIT ON SUSTAINABLE DEVELOPMENT

JOHANNESBURG, SOUTH AFRICA

23 August – 5 September 2002

 

APPLICATION FORM

DEADLINE FOR SUBMISSION: 22 APRIL 2002

 

Please type or use block letters.

 

Full name (as stated in application form): ___________________________________________________________

 

Please describe in 300 words or less how you would benefit from attending the WSSD outlining what you hope to accomplish through your participation.

 

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

Date ____________________ Signature of applicant ____________________________________________

 

Please submit your application to PRB via fax (202.328.3937, attn: Buffy Baumann) or email: bbaumann@prb.org.  If submitting by fax, please send an email notifying us of your intent to do so.

 

Population Reference Bureau

1875 Connecticut Ave. NW, Suite 520

Washington, DC 20009-5728

USA

Fax: 202.328.3937, Phone: 202.483.1100

Web: www.prb.org