Media Credentials Application – Non-Member

First Name *

Last Name *

Email *

Your Position *ReporterPhotographerDirectorEditorProducerCamerapersonTechnician

Organization *

Website

Type of Organization *TVDaily NewspaperWeekly NewspaperRadioNews AgencyOnline OnlyPhoto

I/My Organization Belongs To *Florida Association of BroadcastersFlorida Press AssociationFlorida Public Broadcasting (The Association of Public Media in Florida)None of the Above

I need a parking space for a satellite truckYes - VanYes - Oversized/TruckNo

Media Organization Information

Supervisor Name

Supervisor Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Supporting Documentation

Letter of Assignment

No file chosen

Press Card / Work Pass

No file chosen

Terms of Acceptance and Signature

Electronic Signature *

Please type your First and Last Name

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

2016-08-31

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Before You Vote Partners

Debate Host

Production Partner

Executive Producer

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