Title:
Mr. Mrs. Ms. Dr.
Name:


News Organization:


Mailing Address:




Phone Number:
ext.
Fax Number:


E-mail Address:



How many credentials are you requesting?

Please list the names of those individuals applying for credentials:
1)
2)
3)
4)
5)
6)
7)
8)

Will you need an audio mult-box hook-up?
(No microphones will be allowed on the podium)
Yes No

Will you need a video feed from Dominion Post?
Yes No


Can we provide you anything else to assist you in covering the Mock Convention?: