ARF DiREx 2013 Registration Form for Media

Personal Information
Photo (*)
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Full Name (as appear in passport) (*)
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Gender (*)
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Marital Status (*)
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Date of Birth (*)
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Age (*)
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Nationality (*)
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Country of Birth (*)
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Passport
Passport No. (*)
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Place of Issue (*)
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Date of Issue (*)
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Date of Expiry
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Visa to Thailand (If any)
Visa No.
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Type of Visa
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Place of Issue
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Date of Issue
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Date of Expiry
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Work Permit (If any)
Work Permit No.
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Date of Expiry
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Address in Home Country
Address (*)
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Country (*)
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Zip Code
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Telephone
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Address in Thailand
Address (*)
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Province (*)
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Zip Code (*)
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Telephone (*)
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Organization/Accreditation Information
Organization Name (*)
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Type of Medium (*)
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Headquarters located in City (*)
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Headquarters located in Country (*)
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Bureau Address in Thailand
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Province
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Zip Code
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Telephone
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Term of Contract to Work in Thailand (If any)
From
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To
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Designation
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Name of Reference Person
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Position
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Contact Information
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List of Media Equipment
Device / Type / Serial Number
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Captcha (*) Captcha
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(*) required information