Rabu, 13 Desember 2017

FORMULIR PENDAFTARAN ANUGERAH JURNALISTIK ADINEGORO

ANUGERAH JURNALISTIK ADINEGORO 2012
Formulir Pendaftaran 
 
NOMOR PENDAFTARAN (diisi oleh panitia)  :
 
 
KETIK JAWABAN ANDA, CETAK, LENGKAPI DENGAN TANDA TANGAN, LAMPIRKAN FOTOKOPI KTP & KARTU PERS KEMUDIAN KIRIMKAN MELALUI POS KE PANITIA ANUGERAH JURNALISTIK ADINEGORO
 
BIODATA
 
Nama : ___________________________________________________________________________
Jenis kelamin : Laki-laki / Perempuan (coret yang tidak sesuai)
E-mail : ___________________________________________________________________________
Jabatan : ___________________________________________________________________________
Alamat Rumah : ___________________________________________________________________________
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Telepon Rumah : ___________________________________________________________________________
Handphone : ___________________________________________________________________________
Masa Kerja : Sejak (thn)______________________hingga (thn) __________________________
MEDIA1
Nama Media : ___________________________________________________________________________
Nama Pemimpin Redaksi : ___________________________________________________________________________
Telepon/Handphone : ___________________________________________________________________________
Faksimili : ___________________________________________________________________________
E-mail : ___________________________________________________________________________
Anggota Tim* * : (nama & jabatan) ______________________________________________________
: ___________________________________________________________________________
: ___________________________________________________________________________
 
KARYA DAN WAKTU PENERBITAN / PENAYANGAN / PENYIARAN2
1. Judul : ___________________________________________________________________
Tgl Terbit/Tayang/Siar : ___________________________________________________________________
2. Judul : ___________________________________________________________________
Tgl Terbit/Tayang/Siar : ___________________________________________________________________
3. Judul : ___________________________________________________________________
Tgl Terbit/Tayang/Siar : ___________________________________________________________________
4. Judul : ___________________________________________________________________
Tgl Terbit/Tayang/Siar : ___________________________________________________________________
5. Judul : ___________________________________________________________________
Tgl Terbit/Tayang/Siar : ___________________________________________________________________
** Diisi jika peserta lebih dari satu orang (tim/kelompok)
1 Untuk jurnalis lepas (freelance journalist), isi dengan nama media yang menerbitkan/menayangkan karya.
2 Maksimal (3) tiga judul untuk kategori Tulis, Radio, TV, Siber & Infotainmen dan Maksimal (5) judul untuk kategori Tajuk, Foto & Karikatur, bagi setiap media.
 
KARYA INI DIIKUTSERTAKAN DALAM KATEGORI 3
Jurnalistik Televisi
Jurnalistik Radio
Jurnalistik Siber
Liputan seni, hiburan, dan informasi entertainmen (infotainmen)
RIWAYAT PENDIDIKAN PESERTA (SMA ke atas) dan profil singkat Anda
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PENGALAMAN PROFESIONAL PESERTA 4
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3 Beri tanda centang (v) pada kategori yang dipilih.
4 Cantumkan beberapa liputan penting dan menarik yang pernah dikerjakan selama menjadi jurnalis 
Formulir harus diisi secara lengkap dengan menyertakan seluruh persyaratan yang diminta.
 
TULISKAN CATATAN KISAH PROSES KREATIF KARYA ANDA :
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Sebutkan judul karya yang menang penghargaan lain, dan berikan penjelasan atas kemenangan/penghargaan tersebut :
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MASUKAN
Darimana anda tahu tentang Anugerah Jurnalistik Adinegoro? (boleh lebih dari satu)
iklan di media (sebutkan medianya: ........................................................................................................)
mailing list (sebutkan mailing listnya: ……………………………………..............,,,,............................…………)
website PWI
pelatihan/seminar/diskusi publik yang diselenggarakan PWI
informasi dari teman/atasan/kolega kerja
lain-lain: …………………………………………………………………………………..........................................................
Penghargaan jurnalisme apa lagi yang anda ketahui? (boleh pilih lebih dari satu)
Anugerah Jurnalistik M.H. Thamrin
Mochtar Lubis Award
Sampoerna Adiwarta Award
Anugerah Jurnalistik Pertamina
Anugerah Jurnalistik Aqua
lain-lain: …………………………………………………………………………………..........................................................
 
Pendapat anda tentang Anugerah Jurnalistik Adinegoro :
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PERNYATAAN PESERTA
Dengan ini saya menyatakan bahwa informasi data dan karya yang saya kirim untuk mengikuti Anugerah Jurnalistik Adinegoro 2012 adalah benar dan karya orisinal saya sendiri (di luar penanganan penyuntingan/editing) dan karya ini memenuhi segala ketentuan hak cipta.
Saya juga memberikan persetujuan kepada pihak Anugerah Jurnalistik Adinegoro untuk menyertakan/memuat karya saya (dengan mencantumkan nama saya) pada setiap kegiatan Anugerah Adinegoro 2012, tanpa kompensasi apapun.
 
Saya telah membaca dan menyetujui seluruh syarat dan ketentuan Anugerah Jurnalistik Adinegoro 2012.
 
Nama : ___________________________________ Tandatangan : ____________________________________
(Tanggal : _______________________)
 
Mengetahui:
Pemimpin Redaksi
 
 
Nama : ______________________________ Tandatangan & Cap : __________________________________
(Tanggal : _______________________)