Media Accreditation - Jackalope 2017
IDENTIFICATION
Statut *
First Name *
Your answer
Last Name *
Your answer
Adress *
Your answer
City *
Your answer
Province/State *
Your answer
Country *
Your answer
Phone
Your answer
Cell Phone *
Your answer
Email *
Your answer
Function *
Press Card Organisation *
Your answer
Press Card Number *
Your answer
MEDIA
Name *
Your answer
Type *
Service *
Your answer
Diffusion *
Reach *
Your answer
Web Site *
Your answer
RESPONSABLE
First Name *
Your answer
Last Name *
Your answer
Title *
Phone *
Your answer
Email *
Your answer
* Tribu Expérientiel reserves the right to require a letter from the person in charge to validate the accreditation
ATTENDANCE
Days *
Required
Topics of interests *
Required
Broadcasting date(s) *
Your answer
Requests
Your answer
I understand that Tribu Expérientiel is absolved of any responsibility for material breakdowns and incidents as part of its JACKALOPE event. *
Required
Thank you for your interest in JACKALOPE. A response to your application for accreditation will be sent shortly.
Submit
Never submit passwords through Google Forms.
This form was created inside of Tribu Expérientiel. Report Abuse - Terms of Service - Additional Terms