Conference Directory
*To facilitate networking among conference attendees, we will provide all registrants with a directory of conference participants that includes the contact information you've provided. Please let us know if you would like to be included in the directory. Please select response Yes No
*Name as it should appear on badge:
Organizational Affiliation:
Title/Position:
Are you attending as a representative of this organization?
Mailing Address
*Street Address:
*City:
*State: Please select response AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
*Zip Code
Country: Please select response United States Canada Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma/Myanmar Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Congo, Democratic Republic of Costa Rica Cote d'Ivoire/Ivory Coast Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe
This address is my: Home Organization/Company
*Phone Number
Survey Questions
How did you hear about the National Conference for Media Reform? Please select response Print Ad Email from Free Press Listserv or email from other organization Free Press Website Other Website Brochure/flyer Personal Contact Other
From which magazine, web site, listserv, organization etc. did you hear about the conference?
Are you currently active in media reform work? Please select response Yes No
Have you attended a previous National Conference for Media Reform?
How much do you know about media policy issues? Please select response Beginner Intermediate Advanced
Demographic Information The following optional demographic information will help us better understand who will be attending the conference and help us plan to meet your interests and needs.
Occupation:
Gender
Race/Ethnicity
Age Group
under 25 years
25-40 years
41-54 years
55 years+
Arrival Information
I will arrive for the conference on:
Please select response
Wednesday, June 4
Thursday, June 5
Friday, June 6
Saturday, June 7
Unsure
Special Accommodations Please let us know about any special requests. We will make every effort to accommodate your needs and would appreciate at least three weeks advance notice so that we may make appropriate arrangements.
Special Accommodations
Other/Additional Information: