Mass media accreditation form

Family name

Name

Father’s name

Country

Passport number

Date of birth

Place of birth

Residency

Name of a mass media

Position

Address

Country

Street

Building number, office number

Telephone (with city code, mobile number)

Fax (with city code)

E-mail

What roundtable discussion plan to participate in?

Accommodation needed?

(yes/no)

Filled form send by fax (4212) 30-52-58

Or e-mail: smi@adm.khv.ru