2012 MEDIA PASS APPLICATION FORM
1.MEDIA ADDRESS
MEDIA NAME
COUNTRY
STREET
CITY
POSTCODE
PHONE (incl.area code)
EMAIL
WEBSITE
PUBBLICATION
TYPE
COVERAGE
FREQUENCY
AVERAGE NUMBER of COPIES, or AUDIENCE
2.JOURNALIST
NAME and SURNAME
CATEGORY
PRESS CARD NUMBER
BIRTH DATE DD/MM/YYYY
ADDRESS: STREET
MOB.PHONE (incl.area code)
JOURNALIST EMAIL
JOURNALIST TWITTER
3.ADDITIONAL INFORMATIONS FOR AGENCIES AND FREELANCE
Pubblication requied with text/photos. Please send to press@mototrek.it
I do declare that I am fully indemnified and insured to act as a journalist within all sections of the FIM X-Trial World Championship 17.03.2012 Assago Milano ITALY, and that my press card is up to date. I wholly agree, that in the event of any direct or indirect accident whatsoever, I will not hold responsible The Promoter Attiila Srl, The Organiser Moto Club Lazzate, any appointed member of their permanent or temporary staff or any other persons working under their immediate instruction. Consequently, I therefore agree that I will not seek to claim any damages whatsoever from any of the aforementioned parties in respect of any direct or indirect accident.
This data are collected in accordance with Law 196/2003
