31st KIA - Application Form for E-mail & Air-mail Submission. Please refer to Application Guidelines -1v

/ Ministry of Science, Research and Technology
Iranian Research Organization for Science and Technology (IROST)
31st Khwarizmi International Award (KIA)
Application Form
31-1v /
-  Kindly indicate in the subject of your E-mail : 31 KIA
v  Section I – Applicant Profile Please do NOT send this application form in PDF Format
Personal colour photo
To be attached
(See requested Annex 3) / For applications submitted via Air-mail
CD Rom Included ?Y □ N □
First Name / Title: Prof.□ Dr.□ Mr.□ Ms.□
Family Name / Gender: F □ M □ Date of Birth:
Nationality / Important: for candidates with more than one nationality or residing Place of Birth:
in another country, please submit the Only nationality you wish
to be mentioned if you are selected as a KIA Laureate.
Country / Iranian Residing Abroad: Y □ N □
E-mail (obligatory) / 1-
2 –
Total number of application presented by the same candidate in this same 31st KIA Session:
….One / Two…. Application(s) / One……Application(s)
Field of Research / To complete, please refer to the Codification Table at Section II –C- Field
F….
Father's Name
Occupation
Name and address of the institution your work in , or your scientific affiliation
Position
Office Address
Office Post Address
(City + Country)
Tel. (country code, area code) / ( ) / ‍‍Cell
Phone
Fax
Home Address
Home Post Address
(City +Country)
Tel. (country code, area code) / ( )
Fax

Ω - End of Section I

v  Section II – Details of your Research Work

(Kindly fill out this section II for each research work)

A - Title of
Your Research Work / Important: This item will be published in case the applicant is selected. Please refer to Laureates section in the website.
B - Abstract of
Your Research Work / Please insert the abstract here for a preview for the KIA secretariat.
and copy the same in another page as for the requested Annex 4 see Section IV,
for the scientific committees.
(Not to exceed 150 words).
Please do not mention: "refer to another sheet " kindly insert your abstract in this space,
Important: This item will be published in case the applicant is selected. Please refer to Laureates section in the website.
C - Field Please select one of the following field:
Code / Field / √ / Code / Field / √
F1 / Industry & Technology Management / F8 / Medical Sciences
F2* / Basic Sciences / F9 / Chemical Technology
F3 / Materials & Metallurgy / F10* / Agriculture, Natural Resources, Animal Sciences & Veterinary Medicine
F4 / Electronic & Computer / F11 / Mechanical Engineering
F5* / Nanotechnology / F12 / Aerospace
F6 / Civil Engineering / F13 / Information Technology
F7 / Biotechnology& Basic Medical Sciences / F14 / Mechatronics
F15 / Green Technology
* / For these fields please clarify :……………………
D- Category Please select one of the following categories
Category - C / √
1 C / Invention & Innovation
2 C / Applied Research
3 C / Fundamental Research
4 C / Development Research
E- Details of the stage of development - Please select one of the following Stages:
Stage - S / √
1 S / Pilot plant
2 S / Commercialized
F- Performance - Please select one of the following Performances:
Performance - P / √
P1 / Individual
P2 / Team
G- Have you already applied for the Khwarizmi International Award in previous sessions with a different research work ? □ Y □ N
If yes, please mention the KIA Session: 5th, 6th ,7th ,8th ,9th ,10th ,11th, 12th, 13th, 14th, 15th, 16th , 17th , 18th 19th, 20th, 21st ,22nd ,23rd, 24th, 25th ,26th , 27th, 28th , 29th , 30th
-  Please submit the title of the last research work:
-  Please explain how do both research works differ from each other:
H- Have you already received the Khwarizmi International Award?
□ Y □ N
If yes, please mention the KIA Session : 5th, 6th ,7th ,8th ,9th ,10th ,11th, 12th, 13th, 14th, 15th, 16th , 17th , 18th 19th, 20th, 21st ,22nd ,23rd, 24th, 25th ,26th , 27th, 28th , 29th, 30th
-  Please submit the title of the selected research work:
-  Please explain how do both research works differ from each other:
I- Have you already received any Prize / Award from the I. Rep. of Iran?
Razi Research Festival on Medical Sciences / Farabi Prize on Human Sciences / Others…
J- How did you know about the Khwarizmi International Award?
Website / direct invitation/ invitation from Scientific Institution / Friend / Colleague / Poster / leaflet / Iranian representation / Other
Please specify and submit the E-mail address if any.

Thank you!

Ω Ω - End of Section II

Requested Annexes

Annexes : 7 items

·  Section III – Requested annexes related to the Applicant Profile

Important: In case annexes are too voluminous), Applications may be submitted via Air-mail, they should be sent in a CD Format , indicating the name of the applicant, along with the copy of the Section I and Section II of the application form , in hard copy.

.

Annex 1
/ Complete CV (including list of Employment, Education, Publications, …)
Annex 2
Optional / Copy of your certificates / awards if any
Annex 3 / Personal colour photo attached file jpg / affixed on Section I

Ω Ω Ω - End of Section III – Requested annexes related to the applicant profile

·  Section IV – Requested annexes related to the research work

Kindly attach the following requested annexes for each research work

Annex 4 / Model - On a separate page – At the top of the page, please write the following information:
Annex 4 / Name of the Applicant: / Field of the research work :
Title of the research work
Abstract of the research work (Max. 150 words )
Annex 5 / Model - On another separate page - At the top of the page , please write the following information:
Annex 5 / Name of the Applicant: / Field of the research work:
Title of the research work
Description of the research work (No word limit)
Annex 6 / Copy of all the publications related to your research work
Annex 7
Optional / Photo (s) of your research work
E-mail: / KIA Website: / Tel & Fax:

Please kindly mention: 31st KIA, in the subject of your E-mail. / http://www.khwarizmi.ir
Please regularly consult the website / Tel/Fax: (+98 21) 56 28 63 45
Tel: 56276321 / 56 28 60 38
Air Mail Address:
Iranian Research Organization for Science & Technology (IROST)
(KIA) Secretariat: Ehsani Rad St., ٍEnghelab Road, Ahmadabad Mostoufi, Azadegan Highway, P.O.Box: 335351-11, Tehran 33 13 19 36 85 - I. R. of Iran

1