APPLICATION FORM

Please send this form and all required materials by 20 March 2012 to: ipsasiapacificdesk@me.com 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 8330 Fax (66-2) 261 8331 Personal and Contact Information First name: Age: Date of birth: Last name: Sex: Male Female

Country of residence/work: Home address: Mobile phone: Passport number, date of issue and expiry: Work and Professional Information Type of Media Organisation (please check): Newspaper Magazine (indicate frequency) Web-based publication (url: ________________________ Name of organization:

Nationality:

Email:

News Agency Others (please specify) _____________________________________

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/Supervisors Endorsement
(The applicants 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: o Focused on linking climate change to everyday issues in the Asian development context o Must be published in an article/set of articles totalling 1,000 to 2,000 words in the journalists 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.)