ࡱ> g bjbjVV yr<r<&49vvv$P~LU2H((b!!#7$1111111$M35::1v$ ^!!$$:1(ba2I(I(I($l(:vb1I($1I(I(2.J,0b0!QO%F`0.1%20U20.96%V96\096v0D$$I($$$$$:1:1'^$$$U2$$$$96$$$$$$$$$ :  INTERNATIONAL ATOMIC ENERGY AGENCY (IAEA) WAGRAMER STRASSE 5, PO Box 100, 1400 VIENNA (AUSTRIA) TELEPHONE (+43 1) 2600, FACSIMILE: (+43 1) 26007 E-MAIL: Official.Mail@iaea.org, TC WEB SITE: http://tc.iaea.org  APPLICATION FOR A SCIENTIFIC VISIT Note: This form cannot be used to apply for a training course nor for a fellowship. INSTRUCTIONS PLEASE READ CAREFULLY The IAEA requires two completed copies of this form for each applicant nominated. Please type or print in ink. Section 1-9 To be completed by the applicant. Section 10 To be completed by registered medical practitioner. Section 11: To be completed by the applicant and his supervisor. Section 12: To be completed by the designated certifying official of the nominating Government. BEFORE SIGNING, PLEASE BE SURE THAT ALL QUESTIONS HAVE BEEN ANSWERED. COMPLETE FORMS CAN BE PROCESSED MORE RAPIDLY THAN INCOMPLETE ONES. The IAEA application forms for scientific visits must be submitted to the Agency through governmental channels and priority is given to requests associated with projects of direct benefit to the Member States. Notes To qualify for a scientific visit: the candidate must have worked for at least five years in the field in which the visit is requested, and should hold an appropriate advisory or management position; the duration should be up to a maximum of two weeks; paragraphs 6 and 8 should be completed in English. If a visit to a French or Spanish-speaking host country is requested, an additional translation in the respective language should be provided by the applicant.  INTERNATIONAL ATOMIC ENERGY AGENCY (IAEA) WAGRAMER STRASSE 5, P.O. Box 100, A-1400 VIENNA (AUSTRIA) TELEPHONE (+43 1) 2600, FACSIMILE: (+43 1) 26007 E-MAIL: Official.Mail@iaea.org, TC WEB SITE: http://www-tc.iaea.org  APPLICATION FOR A SCIENTIFIC VISIT Note: This form cannot be used to apply for a training course nor for a fellowship. If the proposed training is project related, give IAEA project code:  FORMTEXT    /  FORMTEXT  /  FORMTEXT     and title:  FORMTEXT      PERSONAL DATA FORMCHECKBOX  Female  FORMCHECKBOX  MaleDate of birth: FORMTEXT      Family name: FORMTEXT      Place of birth: FORMTEXT      (as in Passport)Nationality: FORMTEXT      First name: FORMTEXT      Passport No.: FORMTEXT      RecentComplete mailing address (office):Date of issue: FORMTEXT      photographInst. Name:  FORMTEXT      Place of issue:  FORMTEXT      of candidateValid until: FORMTEXT      Street:  FORMTEXT      Telephone (office): FORMTEXT      P.O. Box:  FORMTEXT      Post Code:  FORMTEXT      Telephone (home): FORMTEXT      Town/City:  FORMTEXT      Fax: FORMTEXT      Region/District:  FORMTEXT      e-mail: FORMTEXT      Country:Web Page:  FORMTEXT      Airport/town nearest to residence:  FORMTEXT      Emergency Phone no.:  FORMTEXT      PRIVATE ADDRESSEDUCATION (commencing with first university degree) FORMTEXT      Years attendedName and place of institutionField of study & Diploma/degreefromto FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT      KNOWLEDGE OF LANGUAGESReadWriteSpeakUnderstand Mother tongue:  FORMTEXT       Other languagesGoodAve- rageNot easilyGoodAve- rageNot EasilyGoodAve- rageNot EasilyGoodAve- rageNot Easily FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      RECENT EMPLOYMENT RECORDYears of serviceName and place ofTitle of positionType of workfromtoemployer/organization FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      DESCRIPTION OF WORKDescribe in detail (in 200 words) the work you have been doing during the past 3 years (Please attach list of any material you may have published)  FORMTEXT         PREVIOUS PARTICIPATION IN AN IAEA ACTIVITY:Have you participated in a previous IAEA activity? If yes, please list each activity below:  FORMTEXT       PRIMARY OBJECTIVES TO BE ACHIEVED BY THE PROPOSED TRAININGOutline in at least 200 words the detailed programme of training you require:  FORMTEXT       If the scientific visit is linked to a Technical Co-operation Project, outline in at least 200 words the roles foreseen by the supervisor or project counterpart upon the applicant s return, and how the training will be of value to meeting the needs of the project objectives:  FORMTEXT      HOST COUNTRY(IES)Indicate the country or countries you would like to visit. The Agency reserves the right to select the appropriate country of training.  FORMTEXT       If you are acquainted with the proposed host country or countries, list the institution(s) you would like to visit. If known, indicate also the names of the individual(s) under whose direction you would like to work.  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Indicate any period when you would not be available.  FORMTEXT       MEDICAL CERTIFICATEI, as a qualified medical doctor, hereby certify that I have examined the above candidate and found him/her in good health, free from infectious diseases and able physically and mentally to carry out any relevant duties away from his/her home.  FORMTEXT       FORMTEXT       FORMTEXT      DateName (printed) and signature of examining physician I hereby certify that the statements made by me in this application are true and complete. If selected for a scientific visit, I undertake to: Conduct myself at all times in a manner compatible with my status as a recipient of an IAEA scientific visit; Spend the full time during the period of the award as directed by the supervising agency in the country of study and by the IAEA; Refrain from engaging in political and commercial activities; Submit a report in accordance with the requirements of the IAEA; Return to my home country at the end of the visit and work in my country for a period of at least two years in the field of peaceful uses of atomic energy; Accept no remuneration other than the travel grant and the salary which is paid to me by my own Government or Institution nor render any services against payment or other form of remuneration; Inform the IAEA whenever there are changes in my status or availability that will affect the terms of my IAEA scientific visit. BEFORE SIGNING PLEASE BE SURE THAT ALL QUESTIONS HAVE BEEN ANSWERED  FORMTEXT       Date Signature of applicant  FORMTEXT       Date Signature of supervisor The Government of  FORMTEXT       is cognizant of the principles and rules pertaining to IAEA-supported scientific visits and nominates the applicant (family and first name(s)):  FORMTEXT       for a scientific visit in (specify topics):  FORMTEXT       and, noting the responses given by the applicant to the questions above, gives assurance that: All information supplied by the applicant is complete and correct; After completion of the visit, the applicant will be offered a suitable position in order to permit him/her to work in his/her country for a period of at least two years in the field of peaceful uses of atomic energy; In case the applicant is already employed, his/her salary will continue to be paid throughout the period of the visit; The applicant will be paid all expenses relating to his/her passport, visa, medical examination and other incidental expenses; All medical costs not covered by insurance which are incurred during the visit due to illness or injury will be met by the Government; No facts are known to the Government regarding the reliability and character of the applicant which would obstruct giving him/her access to nuclear installations or institutions where ionizing radiation is used.  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