Form A by j26QdXa


									                                                                                                            Form A
                                                                                                 IAEA-TM- TM-43486
          International Atomic Energy Agency

Participation Form
         Technical Meeting on the Role of Research Reactors and Related
        Infrastructure in the Development of Nuclear Energy Programmes

                                       4 to 7 December 2012
                                 IAEA Headquarters, Vienna, Austria

To be sent to the competent official authority (Ministry of Foreign Affairs, National Atomic Energy Authority)
for transmission to the International Atomic Energy Agency, Vienna International Centre, PO Box 100, A-1400
Vienna, Austria (Telefax No. +43 1 26007)

 Family name:                                         Given name(s):                               Mr/Ms

 Institution:                       Full address:

                                    For urgent communications please indicate:

                                    Telephone no.:                        Telefax no.:

                                    Email address:

 Nationality:                       Designating government or organization:

 Mailing address (if different from address indicated above):

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