CCNMA Ruben Salazar Journalism Awards
2004 ENTRY FORM
Attach this form with each entry (form may be photocopied)

Complete & print this form.

Please check the category of your entry:
Print Television Radio  Photography


Name(s):
Title(s):
Company:
Address:
City:
 State:  Zip: 
Phone:
   Fax: 
Home address:
City:
 State:   Zip:
Home phone:
 E-mail: 
Title of story/photos:
Where story appeared:
Date published/broadcast:

I declare that the entry abides by the contest rules.

Signature ___________________________________________
Date___________________________
Mail with entry fee payable to CCNMA to:
CCNMA Ruben Salazar Journalism Awards
USC Annenberg School of Journalism
300 S. Grand Ave. Suite 3950
Los Angeles, CA  90071-8110
 For Office Use Only

Date__________________

Check no.__________________