D O T A Z N Ã K - REGISTRATION FORM
D O T A Z N Ã K - REGISTRATION FORM
D O T A Z N Ã K - REGISTRATION FORM
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MINISTERSTVO ZAHRANINÍCH VCÍ R - DBOR AX <br />
<br />
<br />
2482044<br />
D O T A Z N Í K - <strong>REGISTRATION</strong> <strong>FORM</strong><br />
1 Jméno a píjmení rozená<br />
Full name (first name(s), surname) maiden name, if any<br />
................................................................................................................ ..................................................................................................<br />
2 Datum, místo narození a národnost - Date and place of birth and nationality<br />
.........................................................................................................................................................................................................................<br />
den msíc rok místo stát státní píslušnost<br />
day month year place country nationality<br />
3 íslo pasu: íslo obanského prkaz R:<br />
Passport number: I.D. Number (preferably Czech "green" card)<br />
................................................................................ ................................................................................................<br />
4 Adresa bydlišt v zemi pvodu - Place of residence in country of origin<br />
........................................................................................................ ............................................<br />
místo-place ulice-street íslo-No. telefon-phone<br />
5 Adresa bydlišt v R-Place of residence in the Czech Republic<br />
................................................................................................................ ............................................<br />
místo-place ulice-street íslo-No. telefon-phone<br />
Koho zastupujete v R -What foreign media do you represent in the Czech Republic<br />
....................................................................................................................................................................................................................<br />
telefon + fax<br />
6 Adresa zamstnavatele v zemi pvodu<br />
Address of employer in the Czech Republic, if any<br />
...................................................................................................................................................................................................................<br />
Adresa zamstnavatele v R telefon + fax<br />
Address of employer in the Czech Republic<br />
....................................................................................................................................................................................................................<br />
telefon + fax<br />
7 Oblast pracovního zamení - What topics do you cover<br />
..................................................................................................................................................................................................................<br />
8 Dosavadní psobení v zahanií edchozí psobení v R (SSR,SFR)<br />
Previous postings or visits abroad Previous postings or stays in CZ (CS)<br />
................................. .............................................. ......... ................................... ................................................ ...............<br />
................................. ............................................... .......... ................................... ................................................. ..............<br />
................................. .............................................. .......... ................................... ................................................. ..............<br />
................................. ............................................. .......... .................................. ................................................. ..............<br />
mobil phone: .............................................................................<br />
e-mail: .........................................................................................<br />
Znalost jazyk: .......................................................................<br />
Languages:
9 Dotazník vyplte jednou a piložte 3 fotografie Please enclose 3 photos with this form<br />
K dotazníku prosím piložte životopis a povení Please enclose your CV and your employer´s<br />
zamstnavatele confirmation of your current posting<br />
Prohlašuji tímto, že jsem ádn informován/-a o shromažování a zpracovávání mých poskytnutých osobních údaj<br />
za úelem vystavení akreditace zahraniního novináe, v souladu s ustanovením § 11 zák. . 101/2000 Sb., o ochran<br />
osobních údaj, ve znní pozdjších zmn a doplk.<br />
Osobní údaje jsem poskytl/-a dobrovoln a souhlasím s<br />
uveejnním kontaktních údaj na webových stránkách MZV R<br />
poskytnutím kontaktních údaj pípadným zájemcm z ad institucí státní správy a z ad veejnosti<br />
v rozsahu<br />
jméno, píjmení, titul, zastupované médium<br />
poštovní adresa<br />
e-mailová adresa<br />
telefon - pevná linka<br />
mobilní telefon<br />
a to ode dne jejich poskytnutí po celou dobu platnosti vystavené akreditace novináe, i po skonení platnosti, pokud si<br />
je nevyžádám písemn zpt.<br />
I declare that I am duly informed of the collecting and processing of my personal data for the purpose of accreditation<br />
of foreign journalists, in harmony with the provisions of Section 11 of Act No. 101/2000 on the protection of personal<br />
data as amended.<br />
I have provided my personal data voluntarily and I agree with:<br />
The publication of contact data on the websites of the Ministry of Foreign Affairs of the Czech Republic; and<br />
The provision of the contact data to interested parties from among state administration institutions and the<br />
public<br />
Including<br />
Forename, surname, media organization<br />
Postal address<br />
e-mail address<br />
Telephone Number<br />
Mobile/Cell Number¨<br />
as of the date of their provision, during the validity of accreditation and after the expiry of its validity unless I ask in<br />
writing for their return.<br />
Vlastnoruní podpis - Signature<br />
Praha<br />
....................................................………………....... Prague.......................................................20.....
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