ࡱ> 35012 bjbjWW J55A=<""||$P\Q.4t $$$$)^.1pOOOOOOO$RUrPM/3()/3/3P||$$hQ555/3^|$($O5/3O55K+6JO$/kb3v9NPO~Q0QNV4VOVOT/3/35/3/3/3/3/3PP5/3/3/3Q/3/3/3/3V/3/3/3/3/3/3/3/3/3" B:  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.iaea.org/technicalcooperation/  FELLOWSHIP APPLICATION Note: This form cannot be used to apply for a training course or for a scientific visit. INSTRUCTIONS PLEASE READ CAREFULLY The IAEA requires two completed copies of this form for each applicant nominated. Please type or print in ink. Section A (1-10): To be completed by the applicant and supervisor. Section A (11): To be completed by the designated certifying official of the nominating Government. Section B: To be completed by the Government official responsible for atomic energy matters in the country concerned. Section C: To be completed by a registered medical practitioner. Section D: To be completed by a qualified language teacher. Paragraph 6 and 8 from section A should be completed in English. If a visit to a French or Spanish-speaking host country is requested, an additional translation in the respective language should be provided by the applicant. A complete transcript of the academic record is required for each applicant, including the following information about undergraduate or post-graduate courses: Number of semesters or academic years of study: Subjects studies in each semester or academic year; Grade (such as fair, good, very good, excellent or any other code system) for each of the above mentioned subjects; and Degree obtained upon graduation. A certified translation of this transcript is required if it is issued in a language other than that of the requested training programme. BEFORE SIGNING, PLEASE BE SURE THAT ALL QUESTIONS HAVE BEEN ANSWERED. COMPLETE FORMS CAN BE PROCESSED MORE RAPIDLY THAN INCOMPLETE ONES. The IAEA application forms for fellowships must be submitted to the IAEA through governmental channels and priority is given to requests associated with projects of direct benefit to the Member States. The IAEA may consider your requirements are better met by a scientific visit. To qualify for a scientific visit, the candidate must have worked for at least five years in the field in which the visit is requested, and should hold an appropriate advisory or management position; the duration of the visit should be up to a maximum of four weeks, with not more than two weeks at any one institute  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.iaea.org/technicalcooperation/  FELLOWSHIP APPLICATION Note: This form cannot be used to apply for a training course or for a scientific visit. Technical cooperation (TC) project code: RER6/0/ 030 and title: Group Fellowship on Practical Aspects of Medical Radiation Physics in RadiotherapyPERSONAL DATA FORMCHECKBOX  Female  FORMCHECKBOX  MaleDate of birth: FORMTEXT      Family name: FORMTEXT      Place of birth: FORMTEXT      (as in Passport)Nationality: FORMTEXT      RecentFirst name: FORMTEXT      Passport No.: FORMTEXT      photographComplete mailing address (office):Date of issue: FORMTEXT      of candidateInstitute Name:  FORMTEXT      Place of issue: FORMTEXT      Valid until: FORMTEXT      Street:  FORMTEXT      Telephone (office): FORMTEXT      P.O. Box:  FORMTEXT      Post Code:  FORMTEXT      Telephone (home): FORMTEXT      Town/City:  FORMTEXT      Fax: FORMTEXT      Region/District:  FORMTEXT      E-mail: FORMTEXT      Country:  FORMTEXT      Web Page:  FORMTEXT      Airport/town nearest to residence:  FORMTEXT      Emergency Phone no.:  FORMTEXT      PRIVATE ADDRESSEDUCATION (commencing with secondary school) FORMTEXT      Years attendedName and place of institutionField of study & Diploma/degreefromto FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT      KNOWLEDGE OF LANGUAGESReadWriteSpeakUnderstand Mother tongue:  FORMTEXT       Other languagesGoodAve- rageNot easilyGoodAve- rageNot EasilyGoodAve- rageNot EasilyGoodAve- rageNot Easily FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT      FORMTEXT     RECENT EMPLOYMENT RECORDYears of serviceName and place ofTitle of positionType of workfromtoemployer/organization FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      DESCRIPTION OF WORKDescribe 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)  FORMTEXT       PREVIOUS PARTICIPATION IN AN IAEA ACTIVITYHave you participated in a previous IAEA activity? If yes, please list each activity below:  FORMTEXT       PRIMARY OBJECTIVES TO BE ACHIEVED BY THE PROPOSED TRAININGOutline in at least 200 words the detailed programme of training you require:  FORMTEXT       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:  FORMTEXT       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:  FORMTEXT      HOST COUNTRY(IES)Indicate the countries where you would like to be trained. The IAEA reserves the right to select the appropriate country of training.  FORMTEXT       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.  FORMTEXT       Indicate how much time you could devote to the training, and the period when you would be available to undertake the training (please keep in mind it may take several months from submission of application to finalise arrangements). Indicate any period when you would not be available.  FORMTEXT        I hereby certify that the statements made by me in this application are true and complete. If selected for a fellowship, I undertake to: Conduct myself at all times in a manner compatible with my status as a recipient of an IAEA training award; 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; Refrain from engaging in political and commercial activities; Submit reports in accordance with the requirements of the IAEA; 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; 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; Inform the IAEA whenever there are changes in my status or availability that will affect the terms of my IAEA training award. BEFORE SIGNING PLEASE BE SURE THAT ALL QUESTIONS HAVE BEEN ANSWERED  FORMTEXT       Date Signature of applicant  FORMTEXT       Date Signature of supervisor The Government of  FORMTEXT       is cognizant of the principles and rules pertaining to IAEA-supported training awards and nominates the applicant (family and first name(s)):  FORMTEXT       for a fellowship in (specify topics):  FORMTEXT       and, noting the responses given by the applicant to the questions above, gives assurance that: All information supplied by the applicant is complete and correct; 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; In case the applicant is already employed, his/her salary will continue to be paid throughout the period of the award; The applicant will be paid all expenses relating to his/her passport, visa, medical examination and other incidental expenses; All medical costs not covered by insurance which are incurred during the fellowship due to illness or injury will be met by the Government; 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.  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 FORMTEXT       Explain how the applicant s training programme will achieve the above objectives.  FORMTEXT       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.  FORMTEXT      Priority will be given to fellowship applications which are related to projects. If this application is related to an IAEA, 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.  FORMTEXT        FORMTEXT       Date Signature of Government official responsible for atomic energy matters in the country  FORMTEXT       Name and title of official (typed or printed)   MEDICAL REPORT INSTRUCTION: To be completed in duplicate by a registered medical practitioner after a thorough clinical and laboratory examination; a chest X-ray should be included only if clinically indicated. 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:  FORMTEXT       Date of birth (year-month-day)  FORMTEXT      -  FORMTEXT    -  FORMTEXT     FORMCHECKBOX  Female  FORMCHECKBOX  Male Height (cm):  FORMTEXT     Weight (kg):  FORMTEXT    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):  FORMTEXT      What medications are regularly taken by the candidate and what is the reason for each?  FORMTEXT      What is the applicant s normal blood pressure?  FORMTEXT      Is the applicant in good health and able to work at full capacity?  FORMTEXT      Is the candidate able physically and mentally to participate in intensive training away from his/her home?  FORMTEXT      Is the candidate free from infectious diseases (for example tuberculosis or trachoma) which could present risks for the applicant or people with whom he/she will be in contact during his/her period of training?  FORMTEXT      Does the applicant have any medical condition which might require treatment during his/her period of training?  FORMTEXT      (If applicable) Are there any abnormalities indicated by the chest X-ray?  FORMTEXT      Full name and address of examining physician (printed or typed)  FORMTEXT        FORMTEXT       Date Signature and stamp of the examining physician LANGUAGE CERITIFICATE FOR FELLOWSHIP APPLICANTSCERTIFICATE OF KNOWLEDGE OF ENGLISH, FRENCH or SPANISH (as applicable)Name of the applicant:  FORMTEXT       Address of the applicant:  FORMTEXT      Type of test administered:  FORMTEXT       Overall score obtained:  FORMTEXT      Please mark appropriate boxes in sections (1), (2), (3), (4) and (5) below:(1)ABILITY TO UNDERSTAND FORMCHECKBOX Understands without difficulty when addressed at normal rate FORMCHECKBOX Understands almost everything, if addressed slowly and carefully FORMCHECKBOX Requires frequent repetition and/or translation of words and phrases(2)ABILITY TO SPEAK FORMCHECKBOX Speaks fluently, accurately and easily intelligible FORMCHECKBOX Speaks intelligibly, but is not fluent or altogether accurate FORMCHECKBOX Speaks haltingly, and is often at a loss for words and phrases(3)ABILITY TO WRITE FORMCHECKBOX Writes with ease and accuracy FORMCHECKBOX Writes slowly and/or with only moderate degree of accuracy FORMCHECKBOX Writes with difficulty and makes frequent mistakes(4)READING ABILITY AND COMPREHENSION FORMCHECKBOX Reads fluently with full comprehension FORMCHECKBOX Reads slowly, but understands almost everything he reads FORMCHECKBOX Reads with difficulty, and only with frequent recourse to the dictionary(5)OVERALL ASSESSMENT FORMCHECKBOX Applicant s knowledge is sufficient to follow *academic/*practical training programme (*cross out if not applicable): FORMCHECKBOX Without further language training FORMCHECKBOX After  FORMTEXT       months intensive language training in home country at  FORMTEXT       FORMCHECKBOX After  FORMTEXT       months full time training in host country at  FORMTEXT       FORMCHECKBOX After  FORMTEXT       months part time language training parallel with technical training in host country FORMCHECKBOX Applicant s knowledge is insufficient(6)Other remarks which may be of value in the development of the applicant s training programme:  FORMTEXT      Language test has been administered by:Name:  FORMTEXT      Title:  FORMTEXT      Address:  FORMTEXT      Date:  FORMTEXT      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.     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