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PRESS ACCREDITATION



1. Personal Details
 
Salutation * /Title:   Mr. Ms.    Prof. Dr.
Surname *:  
Given Name *:  
Organisation / Medium *:  
Occupation: *:  
Other:
Employment: *:   Employee     Freelance

Postal Address *:  
Postcode *:  
City *:  
Country *:

Phone:  
Fax:  
E-Mail-Address *:  



2. Presscard

Issuer:  
Membership number:  



3. Kind of publication *

  News agency
  Newspaper
  Magazine
  TV
  Radio
  Online  -  Web address:  



4. I will participate on *:

  Wednesday 3 March
  Thursday 4 March
  Friday 5 March



*  I would like to confirm my accreditation to the Galileo Application Days




Obligatory fields are marked with *
 


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