APPLICATION FORM

Please send this form and all required materials by 20 March 2012 to:

or via post to:The Regional Director

IPS Asia-Pacific

Rm 3/6 K Building, 22 Sukhumvit Soi 35

Wattana, Bangkok 10110 Thailand

Tel (66-2) 261 8330Fax (66-2) 261 8331

Personal and Contact Information
First name: / Last name:
Age: Date of birth: / Sex:  Male  Female
Country of residence/work: / Nationality:
Home address:
Mobile phone: / Email:
Passport number, date of issue and expiry:
Work and Professional Information
Type of Media Organisation (please check):
Newspaper / News Agency
Magazine (indicate frequency) / Others (please specify)
______
Web-based publication (url: ______/ 
Name of organization:
Position:
Language of media outlet:
Description of responsibilities/areas of coverage:
Years in media work:
Previous experience in media (please include organizations and dates);
Other professional experience (please indicate organizations and dates);
Language(s):
Writing subjects of interest:
Office address
Office phone / Office fax
Applicant Confirmation
This confirms that the information stated above are true and correct.
______
Signature and Date
Editor/Supervisor’s Endorsement
(The applicant’s editor/immediate supervisor and/or head of organization is to provide necessary information and sign below as reference and endorser.)
This confirms that I am aware of the application of the abovementioned journalist to the ‘Climate Change: A Reporting Lens from Asia’ series. If he/she is accepted, we are allowing him/her to participate in it and fulfill its requirements.
Signature: ______
Name: ______
Designation: ______
Organization: ______
Email: ______
Mobile No: ______

STORY PROPOSAL SHEET

Note: The story you propose for the ‘Climate Change: A Reporting Lens from Asia’ series should fit the following criteria:

  • Focused on linking climate change to everyday issues in the Asian development context
  • Must be published in an article/set of articles totalling 1,000 to 2,000 words in the journalist’s own agency/organization/publication

Name of Journalist:
Name of Organization:
Country:
Summary and background: (Please answer concisely and directly.)
-What do you want to investigate and find out about in this climate change story?
-What is the new, unexplored or under-reported angle in this proposed story?
-Why is it important and interesting?
Country and areas of coverage:(Indicate where you plan to do field interviews, areas where coverage will take place within your country.)
Interviewees/sources and/or images (Indicate the kind of sources you would to interview to give depth to the story, and possible images to be used.)

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