Form C
M7-TR-1804294	
	International Atomic Energy Agency		

Grant Application Form

International Training Course on State System of Accounting for and Control of Nuclear Material

Oak Ridge, TN, United States of America

1 –12 May 2023
To be completed by the participant and sent to the competent official authority (e.g. Ministry of Foreign Affairs, Permanent Mission to the IAEA, or National Atomic Energy Authority) of his/her country for subsequent transmission to the International Atomic Energy Agency (IAEA), Vienna International Centre, PO Box 100, 1400 Vienna, Austria, either electronically by email to: Official.Mail@iaea.org or by fax to: +43 1 26007 (no hard copies needed).
Deadline for receipt by IAEA through official channels: 

Family name: (e.g. Smith)	First name(s): (e.g. John)
	Mr/Ms:	
Mailing address:	Tel.:	
	Fax:	
	Email:	
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/ organization	Title of your position	Type of work	Years worked 
from         to	

					
3. Description of work performed over the last three years:

4. Institute’s/Member State’s programme in field of conference

Date:			Signature of applicant: ______________________________

Date:			Name, signature and stamp of Ministry of Foreign Affairs, Permanent Mission 			to the IAEA or National Atomic Energy Authority ____________________