INTER SERVICES PUBLIC RELATIONS DIRECTORATE
NATIONAL MEDIA REQUEST FORM


1.
Full Name (Print):
2.
Address:
3.
Visitor / Journalist's Appointment / Designation:
4.
Visitor / Journalist's Address:
5.
Name(s) of Media organization(s) you will represent:
6.
Do you have accreditation number / card from External Publicity Wing of Pakistan Ministry of Information and Broadcasting, if yes please provide details:
7.
    
a.
Name of the Sponsor's:
b.
Name of the Sponsor's Media Organization:
c.
Status of Sponsor’s in Pakistan (Individual / Embassy / Media Organization):
d.
Has Sponsor’s informed your presence / visit / media request to External Publicity Wing of Pakistan Ministry of Information and Broadcasting, if yes please provide details:
8.
Visitor / Journalist’s Brief Information:
a.
Name
i.
Family Name:
ii.
Given Name:
iii.
Other Name (Any other name have been you known by):
iv.
Father's Name:
v.
Languages Spoken other than English:
vi.
Medical assistance if required, please mention details:
vii.
Sex:
b.
Father's Name:
c.
Date and Place of Birth:
d.
Passport Number with Date of Expiry:
e.
Issuing Country:
f.
Status
g.
Nationality
i.
Present:
ii.
Previous (if any):
h.
Academic Qualification
i.
Professional / Career Information
j.
Marital Status
k.
Residential Address (in Pakistan):
l.
Residential Address in the Country of Origin:
m.
Telephone Numbers (Include area code)
i.
Office:
ii.
Residence:
ii.
Cell No (Both in Pakistan and Abroad):
n.
E-mail Address:
o.
Special Interest of Individual:
p.
Brief Pen Picture / General Remarks:
9.
Have you previously visited Pakistan (if yes, for what purpose):
10.
If accompanied, please provide full details (on separate request form) who will accompany you as per serial a to p):
11.
Please give away additional jobs / occupations, you have other than media organization:
12.
Personal Emergency Notification (whom do you wish to be informed in the event of serious injury or in case of severe circumstances):
a.
Primary Contact:
i.
Name:
ii.
Relationship to journalist:
iii.
Address:
iv.
Phone Numbers (Include area code):
1)
Home:
2)
Work:
3)
Cell:
b.
Secondary Contact:
i.
Name:
ii.
Relationship to journalist:
iii.
Address:
iv.
Phone Numbers (Include area code):
1)
Home:
2)
Work:
3)
Cell:
13.
Your media organization is responsible for emergency notification of your primary and secondary contacts. Who at your media organization should perform this function?:
a.
Name and Job Title:
b.
Address:
c.
Phone Numbers (Include area code):
i.
Home:
ii.
Work:
iii.
Cell:
d.
Authority for Release of Personal Information:
Do you consent to have personal information released to the persons you have identified in paragraphs 12a and b above (select the appropriate choice):
14.
Affirmation: