Women's Edition 2004 Application Form

You may print this form, complete it by typing or printing clearly, and send it to Deborah Mesce, Women's Edition Coordinator, Population Reference Bureau, 1875 Connecticut Avenue, NW, Suite 520, Washington, DC 20009, USA or fax it to 202-328-3937, or you may complete the form on your computer and e-mail it to [email protected].

Name:
Full job title:
Name of publication/station/news service:
Description of your job duties:


Address:

Telephone number(s):
Fax:
E-mail address:
Mission of your publication/show/service:


Frequency of publication or broadcast:

Size of audience (for publications, provide circulation number as well as estimated number of readers per copy; for radio, number of listeners of your show; for television, number of viewers of your show; for news services, number of subscribers/users):

Please explain in 500 words or fewer why you would like to participate in Women's Edition, how you meet the selection criteria, and what you hope to achieve with Women's Edition. (You may expand this space for your writing or use a separate page.)

Please identify pressing issues concerning women in your country, and describe the role your media organization can play to address them, in 250 words or fewer. (You may expand this space for your writing or use a separate page.)

Please read carefully the commitments required for Women's Edition membership listed in the Call for Applications to which this form was attached. If you agree to these commitments, please sign below. (If you are submitting this form electronically, you may type your name.)

Signature ______________________________________________
Date _______________________________

Supplemental Funding Statement

Applicants are advised to seek financial support from their home organizations or from national or international agencies to cover all or part of their expenses. PRB can provide funding for housing and meals (approximately US$1,600 for eight days in Washington, D.C., at U.S. per diem rates) and airfare (approximately US$2,000) for a limited number of candidates from countries receiving USAID assistance. Tuition of US$1,400 is waived for participants from USAID-funded countries.

Regardless of funding status, qualified candidates are encouraged to submit their applications (including this Supplemental Funding Statement) to PRB by the January 23, 2004, deadline. Confirmation of outside support can be sent separately to PRB as soon as it is available.

____ I will receive funding from the following sponsoring agency:
Contact person/Title:
Name of funding organization:
Mailing address:
Telephone:
Fax:
E-mail address:
Funding (amount) US$________________ will cover ______________________________

____ I have applied for funding from ___________________________________________

____ I am still seeking sponsorship and would like my application to be considered.
(Please forward confirmation of funding to PRB upon notification from sponsor.)