IAEA Scientific Visit Application

If the proposed training is project related, give IAEA project code: and title:

1. PERSONAL DATA

Complete mailing address (office):

Institution name:

Street:

P.O. Box: Post Code:

Town/City:

Region/District:

Country:

Airport/town nearest to residence:

2. PRIVATE ADDRESS

Private address:

3. EDUCATION (commencing with secondary school)

4. KNOWLEDGE OF LANGUAGES

5. RECENT EMPLOYMENT RECORD

6. DESCRIPTION OF WORK

Describe 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)

7. PREVIOUS PARTICIPATION IN AN IAEA ACTIVITY

Have you participated in a previous IAEA activity? If yes, please list each activity below:

8. PRIMARY OBJECTIVES TO BE ACHIEVED BY THE PROPOSED TRAINING

a) Outline in at least 200 words the detailed programme of training you require:

b) Outline in at least 200 words the detailed programme of work you expect to carry out during the next 12 months at your home institute before starting the training you requested:

c) If the fellowship is linked to a Technical Cooperation 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:

9. HOST COUNTRY(IES)

a) Indicate the countries where you would like to be trained.

b) If you are acquainted with the proposed host country or countries, list the institution where you desire training to be arranged. If known, indicate also the names of the individual(s) under whose direction you would like to work.

c) Indicate how much time you could devote to the training, and the period when you would be available to undertake the training. Indicate any period when you would not be available.

10. I hereby certify that the statements made by me in this application are true and complete. If selected for a fellowship, I undertake to:

(a) Conduct myself at all times in a manner compatible with my status as a recipient of an IAEA training award;

(b) Spend the full time during the period of the award in the training programme as directed by the supervising agency in the country of study and by the IAEA;

(c) Refrain from engaging in political and commercial activities;

(d) Submit reports in accordance with the requirements of the IAEA;

(e) Return to my home country at the end of the fellowship and work in my country for a period of at least two years in the field of peaceful uses of atomic energy;

(f) Accept no remuneration other than the fellowship stipend 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;

(g) Inform the IAEA whenever there are changes in my status or availability that will affect the terms of my IAEA training award.

Signature section

11. The Government of is cognizant of the principles and rules pertaining to IAEA-supported training awards and nominates the applicant for a fellowship in

and, noting the responses given by the applicant to the questions above, gives assurance that:

(a) All information supplied by the applicant is complete and correct;

(b) After completion of the training period, 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;

(c) In case the applicant is already employed, his/her salary will continue to be paid throughout the period of the award;

(d) The applicant will be paid all expenses relating to his/her passport, visa, medical examination and other incidental expenses;

(e) All medical costs not covered by insurance which are incurred during the fellowship due to illness or injury will be met by the Government;

(f) 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.

Name and title of official (typed or printed):

STATEMENT BY THE GOVERNMENT OFFICIAL RESPONSIBLE FOR ATOMIC ENERGY MATTERS IN THE COUNTRY

If the proposed training is project related, give IAEA project code: and title:

Name of the applicant (family name and first name(s)):

1. What are the objectives of this proposed fellowship from the Government’s point of view?

2. Explain how the applicant’s training programme will achieve the above objectives.

3. Explain clearly and fully how the experience gained by the applicant on his/her fellowship will be utilized on his/her return home to further the peaceful uses of atomic energy in the country, either with the organization responsible for atomic energy matters or with another national or private-sector institution.

4. Priority will be given to fellowship applications which are related to projects. If this application is related to an Agency, a UNDP or a locally-supported project, please identify the project (by project code, if possible) and give details relating the aims of the fellowship in relation to the project activities.

Name and title of official (typed or printed):

INSTRUCTION: To be completed in duplicate by a registered medical practitioner after a thorough clinical and laboratory examination including an X-ray of the chest.

The International Atomic Energy Agency reserves the right to require the applicant to undergo a further medical examination before he/she takes up his/her fellowship.

Name of applicant:

Date of birth: Female Male Height (cm): Weight (kg):

1. List any abnormalities which are indicated by the chest X-ray:

2. If the applicant has been under treatment during the last three years, please describe the condition, the treatment and the present status of the disease(s):

3. List all medications which the applicant regularly takes; explain the reason for each:

4. What is the applicant’s normal blood pressure?

5. Is the applicant in good health and able to work at full capacity?

6. Is the applicant able physically and mentally to carry on intensive training away from his/her home?

7. Is the applicant free from infectious diseases (for example tuberculosis or trachoma) which could present risks for both the applicant and his/her contact during his/her period of training?

8. Does the applicant have any medical condition which might require treatment during his/her period of training?

Full name and address of examining physician (printed or typed)

CERTIFICATE OF KNOWLEDGE OF ENGLISH, FRENCH or SPANISH (as applicable)

Name of the applicant:

Address of the applicant:

Type of test administered:

Overall score obtained:

Please mark appropriate boxes in sections (1), (2), (3), (4) and (5) below:

(1) ABILITY TO UNDERSTAND

Understands without difficulty when addressed at normal rate

Understands almost everything, if addressed slowly and carefully

Requires frequent repetition and/or translation of words and phrases

(2) ABILITY TO SPEAK

Speaks fluently, accurately and easily intelligible

Speaks intelligibly, but is not fluent or altogether accurate

Speaks haltingly, and is often at a loss for words and phrases

(3) ABILITY TO WRITE

Writes with ease and accuracy

Writes slowly and/or with only moderate degree of accuracy

Writes with difficulty and makes frequent mistakes

(4) READING ABILITY AND COMPREHENSION

Reads fluently with full comprehension

Reads slowly, but understands almost everything he reads

Reads with difficulty, and only with frequent recourse to the dictionary

(5) OVERALL ASSESSMENT

Applicant’s knowledge is sufficient to follow academic/practical training programme

Without further language training

After months intensive language training in home country at

After months full time training in host country at

After months part time language training parallel with technical training in host country

Applicant’s knowledge is insufficient

(6) Other remarks which may be of value in the development of the applicant’s training programme:

Language test has been administered by:

Name:

Title:

Address:

Date:

Signature:

Note: The applicant may be required to undertake language examination(s) to determine proficiency by a representative of the host Government before acceptance is received. Should this be requested the applicant must undertake the test required by the host Government or institution.