INTERNATIONAL ATOMIC ENERGY AGENCY (IAEA)
WAGRAMER STRASSE 5, P.O. Box 100, A-1400 VIENNA (AUSTRIA) TELEPHONE (+43 1) 2600, FACSIMILE: (+43 1) 26007 E-MAIL: Official.Mail@iaea.org, TC WEB SITE: http://www-tc.iaea.org
NOMINATION FOR TRAINING COURSE
Note: This form cannot be used to apply for a fellowship or scientific visit
The Government of nominates the following candidate for the Training Course on (indicate short title, place, dates, project/course number):

Female

Family name:

(as in passport)

First name: Complete mailing address (office): Inst. Name: Street: P.O. Box: Post Code: Town/City: Region/District: Country: Airport/town nearest to residence: EDUCATION (commencing with secondary school) Years attended Name and place of institution from to
Date of birth: Place of birth: Nationality: Passport No.: Date of issue: Place of issue: Valid until: Telephone (office): Telephone (home): Fax: e-mail: WEB Page: Emergency phone:
Recent photograph of candidate

Field of study

Diploma or degree
RECENT EMPLOYMENT RECORD Years of service Name and place of from to employer/organization

Title of position

Type of work
DESCRIPTION OF WORK Type of work done by the candidate during the past 3 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?
Has the candidate been, or will he/she be, involved in any IAEA-supported Technical Cooperation project? (Please identify project and describe the nature of the candidates involvement.)
TC-3 E/Rev.7 (Mar. 01) Old forms (TA-3E, TA-3E/Rev.1-6) should be discarded and not used.
PREVIOUS PARTICIPATION IN AN IAEA ACTIVITY: Has the candidate participated in a previous IAEA activity? If yes, please list each activity below:
RELEVANCE OF THE TRAINING How is the Government going to make use of the training received by the candidate at the course ?

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:
Proficiency in the language of the course

Read Good Average Poor

Write Good Average Poor

Speak Good Average Poor

Understand Good Average Poor

Date MEDICAL CERTIFICATE

Name (printed) and signature of examiner
I, as a qualified medical doctor, hereby certify that I have examined the above candidate and found him/her in good health, free from infectious diseases and able physically and mentally to carry out any relevant duties away from his/her home.
Date GOVERNMENT STATEMENT
The nominating Government gives the following assurances: a) b) All information supplied in this form is complete and correct;
Name (printed) and signature of examining physician
Should the candidate's language qualification prove to be insufficient or should the candidate's state of health not correspond to the examining physician's statement, the nominating Government will accept the responsibility for the consequences and any costs arising therefrom; 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 a participant while he/she is travelling to and from or attending the training course, and it, the nominating Government, undertakes the responsibility for such coverage; 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; 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; 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 (printed) and signature of certifying Government official

INTERNATIONAL ATOMIC ENERGY AGENCY
NOMINATION FOR TRAINING COURSE
Note: This form cannot be used to apply for a fellowship or scientific visit
The Government of: nominates the following candidate for the Training Course on (indicate short title, place, dates):
Family name: First name: Complete mailing address (office):
Date of birth: Place of birth: Nationality: Passport No.: Date/Place of Issue: Validity: Telephone (office): Fax: e-mail:
Recent photograph of candidate
EDUCATION (commencing with secondary school) Years attended Name and place of institution from to

Field of study

Diploma or degree
RECENT EMPLOYMENT RECORD Years of service Name and place of from to employer/organisation

Title of position

Type of work
DESCRIPTION OF WORK Type of work done by the candidate during the past 3 years (Please attach list of any material the candidate may have published)
Has the candidate been, or will he/she be, involved in any IAEA-supported Technical Co-operation project? (please identify project and describe the nature of the candidates involvement.)

FELLOWSHIPS

What fellowships have been awarded to the candidate and which training course(s) has he/she attended ? (indicate year, subject, host institution and place)
TA-3E/Rev.4 (Dec 92) Earlier versions of this form (TA-3E, TA-3E/Rev.1, TA-3E/Rev.2, TA-3E/Rev.) may still be used.
RELEVANCE OF THE TRAINING How is the Government going to make use of the training received by the candidate at the course ?

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: (d) Proficiency in the language of the course:
Read [ ] Good [ ] Average [ ] Poor
Write [ ] Good [ ] Average [ ] Poor
Speak [ ] Good [ ] Average [ ] Poor
Understand [ ] Good [ ] Average [ ] Poor

Date MEDICAL CERTIFICATE

Name (printed) and signature of examiner
I, as a qualified medical doctor, hereby certify that I have examined the above candidate and found him/her in good health, free from infectious diseases and able physically and mentally to carry out any relevant duties away from his/her home.
Date GOVERNMENT STATEMENT
Name (printed) and signature of examining physician
The nominating Government 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 or should the candidate's state of health not correspond to the examining physician's statement, the nominating Government will accept the responsibility for the consequences and any costs arising therefrom; (c) It has noted that the sponsoring organisation(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 a participant while he/she is travelling to and from or attending the training course, and it, the nominating Government, 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 Government as regards the reliability and character of the candidate that would militate against the granting of access to nuclear installations.

Name and title (printed) and signature of certifying Government Official