Venue: INN Secretariat, Materials and Energy Research Centre (MERC), Imam Khomeini Blvd., Meshkindasht, Karaj,
Alborz, Islamic Republic of IRAN
Dates:
2-3 May 2017
NEW APPLICATION FORM
Instructions:
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Please send the current application form in *.doc or *.docx format and *.Pdf simultaneously.
Application form should be typewritten or in capital letters, if handwritten.
Incomplete and unauthorized applications will not be processed.
Mentioning title of the conference/workshop in the subject of your email/letter is essential; otherwise your email/letter is
likely to go un-responded.
Only successful candidates will be notified.
INN will provide free board, lodging (guest house), and airport pick-and-drop service on arrival and departure to
participants from the OIC countries.
PERSONAL INFORMATION
2. GENDER
1. NAME OF APPLICANT
 Male
 Female
First Name:
3. NATIONALITY
Middle Name:
4. TITLE (Prof./Assoc. Prof./ Assist. Prof./Dr. Md./
Dr./Mr./Mrs./Ms./Other)
Last/Family Name:
6. DATE OF BIRTH
5. FATHER’S NAME
(Month/ Day/Year ):
Tel.:
7. CONTACT DETAILS
Residential postal address:
Cell Phone:
Email:
Contact number in case of emergency:
Organization postal Address:
Tel.:
Fax:
Email:
Contact number in case of emergency:
PASSPORT INFORMATION
8. PASSPORT DETAILS
(To Assist Issue of Visa, a Copy of First
Three Pages of the Passport is Required to
be Provided by Foreign Nationals
accompanying with the current
application).
Passport Number:
Place of Issue:
Issuing Authority:
Date of Issue:
Date of Expiry:
PHOTO
(Please insert
your new
photograph
here)
ACADEMIC INFORMATION
9. EDUCATION (provide details of all University qualifications, beginning with the most recent, including any in which you are currently enrolled)
Name of Institution/University/Research
Centre (Please give complete name)
Country
Major field(s) of study
Name of diploma or degree
Date received
or expected
10. PROFESSIONAL POSITIONS (begin with the most recent)
Name of Organization
Country
(Please give complete name)
Job/Positon
Title
Employment Dates (from-to)
Main Responsibilities
11. How would you like to attend in this conference/workshop?
 Speaker
 Virtual (offline) speaker
 Participant with article
 Non-Attending (virtual) participant with article
 Participant without article
12. Have you attended any
workshop/conference/course
held by COMSTECH?
If YES, please give the title,
role (participant/Instructor),
and date of the event.
Role
(participant/Instructor)
Title of the Workshop/Conference/Course
13. How did you hear about this
conference/workshop?
 Newsletter
 Website
 Email or letter
Dates
 Friends or family
 Specify if any other ______________________________
14. How will this conference/workshop help you in your current job? (maximum 100 words)
OFFICIAL DECLARATION
If you have not already sent your scanned of the current item, please do so as soon as possible
15. ONLY for OIC member states applicants
(To be filled and Authorized by the Head of Department))
I hereby recommend Prof./Assoc. Prof./ Assist. Prof./Dr. Md./ Dr./Mr./Mrs./Ms. …………………………………………………… for the
conference/workshop on
“Nanotechnology
and Nanomedicine” as a suitable candidate.
Any additional remarks to support suitability of the candidate ………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………
Name __________________________________________________Designation_________________________________________________
Tel. ____________________________________________________Email address_______________________________________________
Office Address _______________________________________________________________________________________________________
___________________________ Date ______________________
Signature and Official Stamp
Applicants are required to submit their new application (preferably through email) to:
Ms. Dr. Fatemeh S. Torknik
Head of INN Secretariat, Materials and Energy research Center (MERC), Imam Khomeini Blvd., Meshkindasht, Alborz, I.R. Iran
Postal Code: 31787-316
Tel: +98-26-36280040-9
Fax: +98-26-36201888; +98-26-36280029
Email: [email protected]
Note:
 Language of the conference/workshop will be English and no translation facility will be provided.
FOR OFFICIAL USE
ONLY
Received 1st application form
by:
Received 2nd application form
by:
Checked by:
Reason of acceptance/rejection: