Please describe your media organization. Is it print, radio, TV, online or a combination? Does it have a political affiliation? What is its estimated audience (newspaper circulation, TV viewership, etc.)? What else would you like to tell us about your media organization?

Tell us about your responsibilities. Do you supervise others in the newsroom? How many? If you are a reporter or columnist, what do you cover? What else would you like to tell us about your job?

Do you use Facebook, LinkedIn, Twitter, or any other social networks? If so, please tell us how to find you.

Do you know how to blog? Shoot still photographs or video? Edit video?

Briefly list any higher education degrees, institutions and dates.

Briefly describe any overseas work or travel.

Please rate your English language skills. Please note that you do not have to be fluent in English to participate in this program.

(Choose one of the following for each category below: none, beginner, proficient, fluent)

Please rate your Hindi language skills.

(Choose one of the following for each category below: none, beginner, proficient, fluent)

Please rate your Urdu language skills.

(Choose one of the following for each category below: none, beginner, proficient, fluent)

Why do you want to participate in this program?

Participants will be asked to propose story ideas on regional issues in South Asia, and to complete these stories to be broadcast or published in their home media organization. What media organization would you propose to have run your story?

If you are selected to participate in a regional conference in the second phase of this program, you will be grouped with one or more journalists from other South Asia countries. What issues would you like to explore in a journalistic project with journalists from the region?

Please provide two references.

Reference 1

Reference 2

I, the undersigned, understand and agree to the following conditions of the 2012 South Asia Regional Training Program for Journalists from India, Pakistan, Bangladesh, Nepal, Bhutan, Sri Lanka and the Maldvies "New Media, New Challenges: Reporting Best Practices In a New Age":

1. If chosen to be a participant, I will be required to participate in one six-week online course.

2. If chosen to be a participant in the second phase of this program, I will be required to participate in a one-week conference of South Asia journalists in Sri Lanka.

3. I fully understand and agree that it is a condition of this program that spouses or dependents cannot be included nor be accommodated in the program.

4. During the second phase of the program the organizers will pay all travel costs; housing; a per day meal/living allowance; visa costs; and health insurance for the duration of the program in Sri Lanka. I will assume responsibility for all incidental expenses. (The program cannot cover salary or pay honoraria.)

5. If chosen, I am required to return to my home country after the completion of the program.

6. If I extend my stay in the Sri Lanka before or beyond the program, I agree to pay the cost of extending my insurance policy.

Participation in this program is contingent upon my ability to meet all requirements. I certify that all statements in my application are true, to the best of my knowledge. I understand that any participant who violates these rules will be expelled from the program.

Please type your name and today's date in the boxes below. This will serve as an electronic signature and is your written consent to the above conditions.