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Media Famil Program
Media Famil Program Survey
Media & Influencer Assessment Form
General Details
Arrival date
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Departure date
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Full name
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Contact number
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Contact email
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Role-Title
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Representing
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Address
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Please select the most applicable
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Media - Journalist
Content creator - Influencer
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Print and Digital Media Information
Media - publication name
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Media company address
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Social media details
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Category of media
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Print
Digital
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Distribution (eg. Local, Regional, National, Multi National or Global).
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Type of publication (eg. Women's Magazine, Travel section of Newspaper, In-Flight Magazine, Supplement, Special Edition, Standalone Website, Website linked to publication).
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Frequency - How often is the publication printed/distributed? (eg. Daily, weekly, fortnightly monthly, 6 months, annually)
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Reader profile - Description of audience
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Market position - Is it popular or highly regarded
(*)
Yes
No
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Publication date
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Is the story commissioned
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Yes
No
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Story angles - Describe in detail the story angle for each separate story
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Areas of interest - Please list any areas of interest that the journalist has or that the publication has shown in the past
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Media coverage
Photography - Will media be taking photographs
(*)
Yes
No
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Will you be using tripods or any other special requirements
(*)
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Providing PDFs or scans of printed stories or links to audio - video and digital stories - Do you agree
Providing PDFs or scans of printed stories or links to audio - video and digital stories - Do you agree
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Independent arrangements
Will media be making any independent arrangements for their visit to Australia
Yes
No
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Please advise date-time and details
(*)
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Does the media have their own Public Liability insurance
Yes
No
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Participant personal details
Title
(*)
Mr
Ms
Mrs
Miss
Dr
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Gender
Male
Female
Non-binary
Prefer not to say
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First name - as per passport
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Family name - as per passport
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Date of birth
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Passport number
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Passport expiry
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Languages spoken
(*)
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Do you have food restrictions
(*)
Yes
No
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Emergency contact name
(*)
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Emergency contact number
(*)
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Licence type
(*)
Automatic
Manual
Heavy vehicle
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Licence number
(*)
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Interviews
Interview requests - Who would you like to interview
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