NOMINATION FOR TC MEETING	
The Government (nominating authority) of 
Nominates the person indicated below for the following event organized under TC project:    
Event title: ME-RER2014-1807325: - Regional Workshop on Regulatory Framework and Licensing for Small Modular Reactors Deployment, Ottawa, Canada 
Date(s): from 18 to 22 November 2019	
1.	PERSONAL INFORMATION	
Gender:  ☐ Female             ☐ Male	Nationality:  	
Family name (as in passport):  
	2nd nationality (if any): 
	
Middle name (if any, as in passport): 
	Passport No.:  
	
First/given name (as in passport):  
	Date of issue:  YYYY-MM-DD
	
Date of birth: YYYY-MM-DD
	Place of issue: 
	
Place of birth: 
	Valid until:  YYYY-MM-DD
	
2.   CONTACT DETAILS	
Institute name:  	
Institute address:	
PO Box: 	
Zip Code:  	
Town/City:  	
State:  	
Country:  	
Telephones (including country/city codes): 	
Office: 
Home: 
Cellular:  	
Work email: 
Private email: 	
Web: 	
Airport/town nearest to residence:  	
3.	LANGUAGE SKILLS	
Mother tongue: 	Description:	
Language	
Speak	
Read	
Write	

	

	

	

	

	

	

	FLUENT (F)

WORKING KNOWLEDGE (W)
LIMITED (L)	Speak, read and write nearly as well as mother tongue
Engage freely in discussions, read and write more complex material
Limited conversation, reading of newspapers, routine correspondence	
4.	EDUCATION	
Start date: YYYY-MM    	Institution:  
	
(Anticipated) Graduation date:  YYYY-MM    
	Institution city: 
	Institution country: 
	
Education level (achieved): 
	Main course of study:  
	
	Specialization:  
	
Start date:  YYYY-MM    
	Institution:  	
(Anticipated) Graduation date: YYYY-MM    
	Institution city:  
	Institution country: 
	
Education level (achieved): 
	Main course of study:  
	
	Specialization:  
	
5.	WORK EXPERIENCE	
Current job:  ☐  Yes         ☐  No		
Employer:
	Type of business:
	
Job function:
	Exact title of post:
	
Start date - End date: YYYY-MM - YYYY-MM        
	Work location (city/country): 
	
Current job:  ☐ Yes         ☐ No		
Employer:
	Type of business:
	
Job function:
	Exact title of post:
	
Start date: YYYY-MM - YYYY-MM    
	Work location (city/country):
	
Current job:  ☐ Yes         ☐ No		
Employer:
	Type of business:
	
Job function:
	Exact title of post: 	
Start date - End date: YYYY-MM - YYYY-MM       
	Work location (city/country): 
	
6.	HEALTH AND RADIATION	
I declare that I am in good health, free from infectious diseases and able physically and mentally to carry out any relevant duties away from home.	☐ Yes         ☐ No	
If you have a physical disability or medical condition which might limit your ability to perform your assignment, please indicate the limitations below:

	
A certificate of good health signed by a registered medical practitioner dated not more than three months prior to the event must be submitted for:
•	events with a duration exceeding one month; 
•	all candidates over the age of 65 regardless of the event duration.	
Are you covered under a radiation surveillance programme in your country?		
☐ Yes
Please provide the dose records for the past five years.	☐ No
Please provide:
•	A medical certificate or personal declaration of health fitness to work with ionizing radiation;
•	Information on your training in radiological protection;
•	The dose records of the past five years (if available).	
Radiation Surveillance Remarks:

	
7.	DESCRIPTION OF WORK	
Past work done by the nominee which is relevant to the event:	
8.	PREVIOUS PARTICIPATION IN IAEA ACTIVITIES	
Have you been or will you be involved in any IAEA activity?  ☐ Yes         ☐ No
If yes, please list each activity below:

	
9.	COUNTRY APPROVAL	
The nominating authority gives the following assurances: 
•	All information supplied by the applicant is complete and correct; 
•	It is noted that the sponsoring organization(s), host country(ies) and host institution(s) do not accept liability for the payment of any costs or compensation arising from damage to or loss of personal property, or from illness, injury, disability or death of the nominee while he/she is travelling to and from or attending the meeting and it, the nominating authority, undertakes the responsibility for such coverage; 
•	The position of the nominee will be retained for him/her and he/she will continue to receive during the meeting a salary and related emoluments to enable him/her to meet his/her financial commitments in his/her home country; 
•	The selected nominee will conduct himself/herself in a manner compatible with his/her status as a participant in an IAEA event and will refrain from engaging in any political and commercial activities; 
•	No facts are known to the nominating authority regarding the reliability and character of the nominee which would obstruct giving him/her access to nuclear installations or institutions where ionizing radiation is used. 	

SIGNATURE OF COUNTERPART	

NAME: 	

DATE: (YYYY-MM-DD) 	

SIGNATURE OF NLO 	

NAME: 	

DATE: (YYYY-MM-DD)