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Deadline: Oct. 27, 2005
Program Dates: Nov. 17 to 19, 2005
en Español
Date: __________________
PERSONAL DATA:
Mr or Ms:______Last names:________________________________ First name:________________________
Date of birth: __________________________ Citizenship:___________________________________________
Name of media:________________________________________ Title: ________________________________
Work address:_______________________________________________________________________________
Work telephone: _______________________________Work fax: ____________________________________
Email: _____________________________________ Home telephone: ________________________________
How did you hear about this program? _________________________________________________________
YOUR MEDIA OUTLET:
(If it is a newspaper, please fill out the first three lines. If it is TV or radio, describe below.)
Published _____ times per week; Sunday edition: YES ____ NO _____
Circulation: _________________________
Number of journalists in the newsroom:____________________
Describe your media in detail: ____________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
EMPLOYMENT EXPERIENCE:
What is your current position? ________________ How long have you been in this position? _______
Years of work experience in journalism: _____________________________________________________
Please describe your primary tasks: ________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe your previous employment and your responsibilities in those posts:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
EDUCATION:
Briefly list any higher education degrees, institutions and dates:
______________________________________________________________________________________
______________________________________________________________________________________
EXPERIENCE COVERING ENVIRONMENTAL TOPICS:
Please describe the stories you have done -- or want to do -- on air quality and other environmental topics:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Employer agreement:
I, the signatory and employer of the applicant, accept that he/she participate in this workshop in order to obtain immediate and longer-term stories on air pollution and its effects on Latino communities.
NAME: ________________________________________________
DATE: ________________________________________________
TEL: __________________________________________________
SIGNATURE: __________________________________________________________________
Completed applications must be submitted on or before October 27, 2005 to:
Celia Bhattacharya, Program Officer
International Center for Journalists
1616 H Street, N.W.
Washington, DC 20006
Tel: 202/737-3700 Fax: 202/737-0530 Email: aire@icfj.org
(Please submit your application by fax or email)
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