INTERNATIONAL ATOMIC ENERGY AGENCY (IAEA)

WAGRAMER STRASSE 5, PO Box 100, 1400 VIENNA (AUSTRIA)

TELEPHONE (+43 1) 2600, FACSIMILE: (+43 1) 26007

E-MAIL: Official.Mail@iaea.org, TC WEB SITE: http://tc.iaea.org

PERSONAL HISTORY

FOR ASSIGNMENT AS TECHNICAL COOPERATION EXPERT

Note: This form cannot be used to apply for a scientific visit.

INSTRUCTIONS

Completion and Usage of the PHF

This form should be completed accurately. Selection for a technical cooperation expert post depends on clearance by the requesting Government.

Please note that unless an office address is indicated, the Agency will use your home address for all official purposes.

Keep a copy of these forms for your own file, and as soon as there are significant changes to the information provided (change of address, additional education/experience, etc.), please notify the Agency accordingly. A PHF is normally valid for 2 years.

The information provided should be as complete and detailed as possible. For example, description of your professional experience (PART B) should not be limited to general references to a position as "Professor", "Research Associate", "Technical Adviser", etc., without any further explanations; or to duties as "Research and Development" without stating the field of research or what was being developed. Emphasis in the completion of that part should be placed on the objectives and responsibilities of the position(s) you have been holding, any major accomplishments, and familiarity with any particular equipment/machinery, etc. Also, should you be filling in this form in connection with a specific expert assignment, the relevant qualifications and expertise required should be highlighted under Specializations in Part B.

Extra pages may be added if required.

Please do not submit any publications with the PHF, but attach a list thereof (listing the titles, publisher, year of publication).

Whenever you are considered for a specific assignment, Part B of the PHF is forwarded -- on a confidential basis -- to the recipient Government for their concurrence on your candidature. The information provided in Part A is treated as confidential and not released to any person or organization outside the Agency.

INTERNATIONAL ATOMIC ENERGY AGENCY (IAEA)

WAGRAMER STRASSE 5, PO Box 100, 1400 VIENNA (AUSTRIA)

TELEPHONE (+43 1) 2600, FACSIMILE: (+43 1) 26007

E-MAIL: Official.Mail@iaea.org, TC WEB SITE: http://tc.iaea.org

PERSONAL HISTORY

FOR ASSIGNMENT AS TECHNICAL COOPERATION EXPERT

Note: This form cannot be used to apply for a scientific visit.

A - ADMINISTRATIVE INFORMATION
If known, give IAEA project code and title : / /	Title:

Personal Data
Female Male
Family name:
Date of birth (yyyy-mm-dd):
(as in Passport)
Place of birth:
First name:
Nationality:	Recent
Complete mailing address (office):
Telephone (office):	photograph
Inst. Name:
Fax:
e-mail:
Street:
Web Page:
P.O. Box:	Post Code:
Emergency Phone no.:
Town/City:
Region/District:
Airport/town nearest to residence:
Country:
Home Address (please indicate full address)
Street:	Telephone (home):
P.O. Box:	Post Code:	Fax:
Town/City:	e-mail:
Region/District:
Country:
Health (a medical examination may be required depending upon the length of appointment and age of the applicant)

If you have a physical disability or medical condition which might limit your ability to perform an assignment under difficult conditions or travel by air, please indicate the limitations:

Radiation surveillance: Are you covered under a radiation surveillance programme in your country?

yes no

I certify that the statements made by me in PART A of this form are true, complete and correct to the best of my knowledge and belief. I understand that I might be requested to provide documentary evidence in support of my statements. If necessary, I will obtain release from my employer.

Date:
Signature:

INTERNATIONAL ATOMIC ENERGY AGENCY (IAEA)

WAGRAMER STRASSE 5, PO Box 100, 1400 VIENNA (AUSTRIA)

TELEPHONE (+43 1) 2600, FACSIMILE: (+43 1) 26007

E-MAIL: Official.Mail@iaea.org, TC WEB SITE: http://tc.iaea.org

PERSONAL HISTORY

FOR ASSIGNMENT AS TECHNICAL COOPERATION EXPERT

B - PROFESSIONAL INFORMATION Project No. (if known)
Name: Mr/Ms.
Nationality:
Date of birth:

Telephone No.

Fax No.:

e-mail:
Type and No. of national passport:

Place of issue:

Date of issue:

Validity

Father’s full name:

Mother’s full name:

KNOWLEDGE OF LANGUAGES	Read	Write	Speak	Understand
Mother tongue:

Other languages	Easily	Not easily	Easily	Not Easily	Easily	Not Easily	Easily	Not Easily
EDUCATION (scientific, technical and professional education; start with the highest degree, certificate or diploma)
Dates attended	Name and location of institution of learning	Academic degrees, certificate or diplomas obtained	Main field of study
From	To
List the specializations in which you consider yourself qualified:

PROFESSIONAL EXPERIENCE (Start with your most recent position)
From:	To:	Title of position:
Employer (name and address) and type of business:

Number and kind of staff supervised:

Duties:

PROFESSIONAL EXPERIENCE (continued)

From:	To:	Title of position:
Employer (name and address) and type of business:

Number and kind of staff supervised:

Duties:

From:	To:	Title of position:
Employer (name and address) and type of business:

Number and kind of staff supervised:

Duties:

List any significant publications or papers you have written which are relevant to your specializations:

List any lecturing experience you have (topics, duration):

List specific experience, not given above, related to the transfer of scientific and technical knowledge with special emphasis on developing countries and on project management:

List special qualifications and skills confirmed by licenses held and membership in professional, civic, public or international societies or institutions relevant to your application:

3

P-2 TCPH Ex. E/Rev. 5 (Mar. 01); Old forms (P-2/TCPH-A/E/Rev. 4 (nov 97) and P-2/TCPH-B/E/Rev. 3 (nov 97)) should be discarded and not used.

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2013-05-07

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