This page is to be mailed or faxed with documentation.

  INET 97 Media Accreditation Form

  PREFIX:   
  Mr ____ Ms ____ Mrs ____ Dr ___  Prof ___

  NAME:________________________________________________________________
  (First Name)(Initial/Middle Name)(Last Name)(Suffix)  

  BADGE NAME:__________________________________________________________

  TITLE:_______________________________________________________________

  AFFILIATION:_________________________________________________________

  ADDRESS:_____________________________________________________________

  CITY:________________________________________________________________

  STATE/PROV:__________________________________________________________

  POSTAL CODE:_________________________________________________________

  COUNTRY:_____________________________________________________________

  WORK TELEPHONE:__________________________

  HOME TELEPHONE:__________________________

  FAX:_____________________________________

  EMAIL:___________________________________

  NAME OF PUBLICATION/AFFILIATION:______________________________________

  For TV journalists, please indicate the name and title of accompanying
  staff (director, cameraman, technician, etc.), if
  any.__________________________________________________________________
  ______________________________________________________________________
                                
  CATEGORY Job Title:

  _____Business Reporter/Editor
  _____Technology Reporter/Editor
  _____General Assignment Reporter
  _____Editor
  _____Other____________________

  CATEGORY Media:       
  _____Technology Publication
  _____Business Publication
  _____General Circulation Newspaper
  _____General Circulation Magazine
  _____Radio
  _____Television
  _____Press Agency/Wire Service
  _____Other_____________________       

  Documentation (one is required)
  ____ photocopy of a valid press card
  ____ letter of accreditation from the Editor-in-Chief (or the News Editor for radio/TV) 
  ____ recent copy of the masthead or TV/radio program listing with your name


  Mail completed form and documentation to:          
  The Internet Society
  12020 Sunrise Valley Drive
  Suite 210
  Reston, VA.  20191-3429 
  USA

  OR
  
  Facsimile completed form and documentation to:   
  Fax.+1 (703) 648-9887