SADC MEDIA AWARD

ENTRY FORM

Photograph

PART I
A. PARTICULARS OF PARTICIPANT (to be completed in block / capital letters)
1. Full name:
Surname: _________________________________________________________________________
Other / First________________________________________________________________________
2. Residential Address: ________________________________________________________________
_________________________________________________________________________
Phone . ________________ Fax _____________________ Email ____________________________
3. Business/ Employers Address: _______________________________________________________
_________________________________________________________________________
Phone . ________________ Fax _____________________ Email ____________________________
4. Nationality _________________________________________________________________________
Date and Place of birth ____________________________________________________________
Passport No ____________________________________________________________________
Date and Place of issue ___________________________________________________________
Date of Expiry

___________________________________________________________

5. Position and brief background

Member States

Angola

Lesotho

Mauritius

Botswana
D.R.Congo

Madagascar
Malawi

Mozambique

Namibia

Seychelles
South Africa
Swaziland
Tanzania

Zambia
Zimbabwe

B.

PART II
DETAILS OF WORK

1. Category (specify) ____________________________________________________________________

2. Title of work _________________________________________________________________________
3. Summary of work ____________________________________________________________________

4. Name of Media ______________________________________________________________________

5. Date and Place of Publication / Broadcasting _______________________________________________
6. Name of Publication / Broadcaster _______________________________________________________
7. Format _____________________________________________________________________________
8. Length / Duration _____________________________________________________________________

PART III
C. DECLARATION
I have read and accepted the rules and regulations of the competition and that the work submitted is of my
own creation.

Date ___________________ Signature ___________________________________________________

PART IV
D. EDITORS ENDORSEMENT
1. This is to certify that this article for submission was written by (indicate name)
_________________________________________________________________________________ and
published by_____________________________________________ on (date) ____________________

Editors Full Name _____________________________________________________

Date . __________________ Signature _____________________________________________________

PART V
E. FOR OFFICIAL USE ONLY
2. Date of receipt _______________________________________________________________________
3. Name / Title of work __________________________________________________________________
4. Received by Full Name ______________________________________________________________
5. Does the work qualify?
YES
NO

6. Remarks ___________________________________________________________________________

Date . __________________ Signature _____________________________________________________

OFFICIAL STAMP