Venue: INN Secretariat, Materials and Energy Research Centre (MERC), Imam Khomeini Blvd., Meshkindasht, Karaj, Alborz, Islamic Republic of IRAN / Dates:
2-3May 2017
APPLICATION FORM
Instructions:
  • 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.
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PERSONAL INFORMATION
1.NAME OF APPLICANT
First Name:
Middle Name:
Last/Family Name: / 2. GENDER  Male Female
3. NATIONALITY
4. TITLE (Prof./Dr./Mr./Mrs./Ms./Other)
5.FATHER’S NAME
6. DATE OF BIRTH (Month/ Day/Year ):
7. CONTACT DETAILS
Postal address of applicant: / Tel.:
Fax:
Contact number in case of emergency:
Email:
8. PASSPORT DETAILS
(To Assist Issue of Visa, a Copy of First Three Pages of the Passportis Required to be Provided byForeign Nationals). / Passport Number:
Place of Issue:
Issuing Authority: / Date of Issue:
Date of Expiry:
9.Have you attended any workshop/conference/course held by COMSTECH?
If YES, please give the title, role (participant/Instructor), and date of the event. / Title of the Workshop/Conference/Course / Role (participant/Instructor) / Dates
10.How did you hear about this conference/workshop? /  Newsletter
 Website
 Email or letter /  Friends or family
 Specify if any other ______
11. How will this conference/workshop help you in your current job? (maximum 100 words)
12. How would you like to attend in this conference/workshop?  Speaker Participant with article  Participant without article
13. OFFICIAL DECLARATION(to be filled and Authorized by the Head of Department). ONLY for OIC member states applicants
I hereby recommend Prof./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 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
Email:
Note:
  • Language of the conference/workshop will be English and no translation facility will be provided.

FOR OFFICIAL USE ONLY / Received by: / Reason of acceptance/rejection:
Checked by: