2022 Japan-IAEA Nuclear Energy Management School
19 July 2022 to 5 August 2022

Nomination for Japan-IAEA Nuclear Energy Management School 
Note: This form is only to be used for the Japan-IAEA Nuclear Energy Management 
through JAIF International Cooperation Center (JICC)
	
The Institute of		
Nominates the following candidate for Japan-IAEA Joint Nuclear Energy Management School.	
				
	□ Female             □ Male		Date of birth: 		
	Family name (as in passport): 		Place of birth: 		
	Middle name (if any, as in passport):		Nationality: 		
	First name (as in passport): 		Telephone (office): 	Recent	
	Complete mailing address (office):
		Telephone (home): 	Photograph	
	Inst. Name:  		Fax: 	of candidate	
	Address:  		e-mail (office):  		
	         		e-mail (home):		
	P.O. Box:  	Post Code: 		Mobile phone:		
	Town/City:  				
	Region/District:  			
	Country:   			
	
EDUCATION (commencing with University or Technical college )	
Years attended	Name and place of University or Technical College 	Field of study	Diploma or degree	
from	to				

	

	

			

			
RECENT EMPLOYMENT RECORD	
Years of service	Name and place of	Title of position	Type of work	
from	To	employer/organization			

			

	

	
DESCRIPTION OF WORK	
Type of work done by the candidate including the work experience in the nuclear field at least for 2 years　(Please attach list of any material the candidate may have published)

Is the candidate covered under a radiation surveillance programme in his/her home country?       □ yes      □ no

Has the candidate been, or will he/she be, involved in any IAEA-supported event?
(Please identify project and describe the candidate’s involvement in it.)

PREVIOUS PARTICIPATION IN AN IAEA ACTIVITY:	
Has the candidate participated in a previous IAEA event?   If yes, please list all events below:

RELEVANCE OF THE TRAINING 　(fill out in detail by the candidate)	
How will the candidate make use of the fruits of the Management School for his/her current and/or future job?

	
LANGUAGE CERTIFICATE	
I, as a qualified language examiner, hereby certify that I have examined the above candidate and give the following information on his/her language qualification:	
(a) Mother tongue of the candidate:			
(b) Other languages:			
(c) Language of the course (English):			
			
	Read	Write	Speak	Understand	
Proficiency in the language	□  Good	□  Good	□  Good	□  Good	
of the course	□  Average	□  Average	□  Average	□  Average	
	□  Poor	□  Poor	□  Poor	□  Poor	

	
				
	Date		Name (printed) and signature of examiner	
INSTITUTE STATEMENT		

The nominating Institute gives the following assurances:

a)	All information supplied in this form is complete and correct;

b)	Should the candidate's language qualification prove to be insufficient, the nominating Institute will accept the responsibility for the consequences arising therefrom;

c)	It is noted that the sponsoring organization, host country and host institution 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 a participant while he/she is travelling to and from or attending the training course, and it, the nominating Institute, undertakes the responsibility for such coverage;

d)	The position of the candidate will be retained for him/her and he/she will continue to receive during the training course a salary and related emoluments to enable him/her to meet his/her financial commitments in his/her home country;

e)	If selected, the nominee will conduct himself/herself in a manner compatible with his/her status as a participant and will refrain from engaging in any political and commercial activities;

f)	No facts are known to the Institute 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.

	

	
	Date		Name and title (printed) and signature of certifying Institute official