20 Rust Street, St Clair, Port of Spain, TRINIDAD (868) 628-4955

acmmail@gmail.com – www.acmediaworkers.com

Please complete the following and return. An annual Membership Fee of US$20 is payable.

Personal Information

Surname ____________________First name(s) ___________________________

Home address ______________________________________________________

_______________________________________Country ____________________

Email Address ______________________________________________________

Tel work_________________________ Home_____________________________ Mobile________________________
Date of birth ______________________________    Sex: M   F 
Do you belong to a national association?  Yes  No       If yes, which one? _________________________________ _________________________________

Professional Details

Freelance   Staff    Please tick one Employer_______________________________________________________________

Job title _______________________________________________________________

Years Media Experience ___________

If you are a freelance journalist please provide the following information:

Percentage of total income derived from journalism ____ %

Applicant’s declaration

I confirm that the above information is correct and that I agree to abide by the rules and code of conduct of the Association of Caribbean MediaWorkers. Yes   No