Interviewer (full name)

Media Organization

Registration No.

Country/Region of Media organization

Telephone

Mobile

E-mail

Interviewee & title

Venue

event

Questions or topics you are interested in

Expected time of interview                    /At interviewee's convenience

Signature

Date of Application    _____/______/2008

FOR OFFICIAL USE ONLY

                                                          Person Handling�� 

                                                          ���ڣ�2008/_____/______