Salutation/Titulo

First Name/Nombre

Surname/Apellido

Date of Birth/Fecha de Nascimiento

01020304050607080910111213141516171819202122232425262728293031 / 010203040506070809101112 / 2000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901

National Press Card / Passport Number - Carnet de Prensa / Passaporte

Nationality / Nacionalidad

Country where based / País

Name to appear on Badge / Nombre para pase
(max 30 characters)

Media Outlet Name to appear on Badge / Medio de communicación
(max 30 characters)

Media Outlet Address / Dirección

Publication Website / Sitio Web

Job Title / Cargo

Mobile No.

Email

Documents upload / Adjuntar documentos
(e.g. national press card, letter of assignment)

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