(Please print in block letters)
Applicant's Name:
............................................................ ..................................................
Applicant's Address:
............................................................ ..................................................
............................................................ ..................................................
Phone: Business (.......) ............................... Home (.......)
..............................
NOMINATED BY:
(name and address if you are nominating a person other than yourself)
........................................................ ......................................................
.. ............................................................ ................................................
Phone: Business (.......) ............................... Home (.......)
..............................
ARTICLES/OR PROGRAM/S BEING SUBMITTED FOR THE AWARD:
(include date/s, media/medium, title/s, place of broadcast/publication and
any other information you think relevant)
........................................................ ......................................................
.. ............................................................ ................................................
........ ............................................................
..........................................
.............. ............................................................
....................................
DESCRIPTION OF ENCLOSED SUPPORTING MATERIAL:
(e.g., tapes, scripts, copies or photocopies of article/s)
............................................................ ..................................................
............................................................ ..................................................
I declare that the above information is to the best of my knowledge true,
and that the applicant has been ordinarily resident in Australia for the
twelve months preceding 30 June 2004;
............................................................ .....................(signature)
.......................................(date)
Please attach any other information which you think is relevant to your
application.
PLEASE FORWARD THIS COMPLETED APPLICATION FORM AND ALL SUPPORTING MATERIAL,
TO BE RECEIVED BY FRIDAY AUGUST 27, 2004 TO:
The George Munster Award,
Australian Centre for Independent Journalism,
University of Technology, Sydney,
PO Box 123, Broadway NSW 2007.
Phone (02) 9514 2488
