Regional Training Course on Nuclear Security in Practice: Field

PARTICIPATION FORM

Regional Training Course on Nuclear Security in Practice: Field

Training for University Students

Obninsk, Russian Federation, 21 October-1 November 2013

________ National Research Nuclear University “Moscow Engineering Physics Institute”, _____________

________ Kashirskoe shosse 31, Moscow, 115409, Russian Federation ______________________________

^{(Full name and official mailing address of the nominating University)}

Student’s Name:	Egorov
First name / Father’s name	Alexander	Aleksandrovich
Date of Birth: (DD.MM.YYYY)	25.12.1986	Gender: ( M/F)
Place of Birth:	Moscow Russia
City	Province	Country
Nationality / Citizenship:	Russian Federation
Passport Number:	?????????????	Date of Expire:	25.12.2031
Issued by:	PVO OVD of Kuzminki District of Moscow, 30.01.2007
University Faculty/Institute:	Faculty of Physics and Technology
Specialization:	Nuclear Material Physical Protection
Course / Semester	6/11
Contact Phone/Fax Number:	phone: +7 916???-8667
Contact Email Address	_________@________
Official contact person at the nominating University responsible for students on this training (Name, position, phone, email address)	Krasnoborodko Andrey Albertovich, Associate professor, dept. 5, Phone: [phone]*95-06, e-mail: [e-mail]	Financial support requested:
YES	NO
As authorized official of the above university, I hereby propose Mr /Ms _ Egorov ____________________ to participate in this training course and agree on his/her travel to Obninsk in accordance to the principles specified in the prospectus.
Date: 14 June 2013	Name and title (printed) and signature of the authorized university official on behalf of Rector: Vice rector / Kryuchkov E.F./

To be received by the International Atomic Energy Agency,

Vienna International Centre,

P.O. Box 100, A-1400 Vienna, Austria;

Fax: [phone] / Email: [e-mail]

Deadline: 14 June 2013

Дата добавления: 2015-11-04