Form C Grant Application Form - International Atomic Energy Agency

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Form C
IAEA-CN-194
International Atomic Energy Agency
Grant Application Form
Third International Conference on Nuclear Power Plant Life Management
(PLiM)
Salt Lake City, Utah, USA, 14-18 May 2012
To be completed by the participant and sent to the competent official authority (e.g. Ministry of Foreign Affairs
or National Atomic Energy Authority) of his/her Member State of the IAEA for subsequent transmission to the
International Atomic Energy Agency (IAEA), Vienna International Centre, P.O. Box 100, 1400 Vienna, Austria
either electronically via email to or via Fax to: +43 1 26007 (no hard copies needed).
Participants of organizations invited to participate can submit this form to their organization for subsequent
transmission to the IAEA.
Family name:
Given name(s):
Mr/Ms:
Mailing Address:
Nearest airport:
Telephone no.:
Telefax no.:
Email address:
Date of Birth (yy/mm/dd):
Nationality:
1. EDUCATION (Post-Secondary)
Name and Place of Institution
Field of Study
Diploma or Degree
Years attended
from
to
2. RECENT EMPLOYMENT RECORD (Starting with your present post)
Name and Place of employer/
Title of your
Type of work
Years attended
organization
position
from
to
3. DESCRIPTION OF WORK performed over the last three years:
4. INSTITUTE'S/MEMBER STATE'S PROGRAMME IN FIELD OF MEETING
Date:
Signature of Applicant: ______________________________
Date:
Name, Signature & Stamp of responsible Government official:
_____________________________

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