Gender and Media Connect

Gender and Media Awards

Entry Form

(PLEASE FILL ALL THE DETAILS IN BLOCK LETTERS)

TYPE OF ENTRY: Individual

CATEGORY OF ENTRY (please tick the box)

PRINT: News Story Feature Story Specialised Report

Radio Plays Investigative Report

TELEVISION: News Story Feature Story Documentary

RADIO: News Story Feature Story Documentary

GRAPHICS AND IMAGES: Photographs Cartoons

DETAILS OF ENTRY: (If you are submitting more than one entry, please attach a separate sheet listing out the
entries and categories)

*Title: ____________________________________________ Language:____________________

*Published In / Broadcast In: ___________________

*Date of Publication / Broadcast In (dd/mm/yy): _____________________________

*Full Name: ______________________________________________________________________

(FIRST NAME) (LAST NAME)

Age: ______________

*Contact / Mailing Address:__________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Telephone: (Work.) ___________________________ *(Mobile) ______________________________

*E-mail: _________________________________________________________________________

If employed, please give following details;

Name of the Publication/ TV Station/ Radio Station:

________________________________________________________________________________

Designation: ______________________________________________________________

Address of the Publication/ TV Station/ Radio Station/

________________________________________________________________________________

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 Telephone: ________________Web URL: ______________________________________________

If you are a freelancer, please give the details of agencies/ publications/ TV channels/ radio stations/ Web Portals to which
you contribute. ________________________________________________________________________________

________________________________________________________________________________

What has been the impact of your story/ies? (Please attach a separate sheet)

Declaration by the applicant:

I hereby declare that all the information provided in the entry form is true to the best of my knowledge and the work
being submitted is original work and has not been copied from any other source. I have not been involved / implicated
in any case of sexual harassment, gender violence, intellectual property rights infringement or professional misconduct.

Note: If you have been involved / implicated in any case of sexual harassment, gender violence, intellectual property rights
infringement or professional misconduct, please attach a separate sheet to provide details about the status of the case.

Signature: Date:

Brief Bio-data: Submit a brief bio data, including awards/ fellowships received or special assignments taken up, not exceeding 250
words (attach a separate sheet).

Gender and Media Connect reserves the right to accept or reject your entry.

If employed, submit an endorsement of the entry by the Reporting Head/ Immediate Supervisor/ Employer*

I hereby certify the enclosed entry to Gender and Media Awards as the original work of:

Ms/ Mr: _________________________________________________________________________

Signature of person endorsing the entry: _____________________

Name: __________________________________________________________________________

Designation: _____________________________________________________________________

Organization: ______________________________Date (dd/mm/yy): _________________________

Please super scribe on the envelope "Entry for The Gender and Media Awards " and deliver at 34 Colenbrander Road,
Milton Park, Harare or email: info@gmc.org.zw
_________________________________________________________________________________

The entries should reach the following address by 31st October 2017

GENDER AND MEDIA CONNECT GENDER AND MEDIA AWARDS 2017 Page 1