Designation of Beneficiary and Emergency Contact Form

Event Number:

Designation of Beneficiary

I, …………………………………………………………………….born on…………………………..

(Family name, First name) (Date, Month, Year)

revoking any and all previous designation of beneficiary made by me concerning funds that are or maybe

owed to me by the International Atomic Energy Agency (IAEA), do now designate the beneficiary or

beneficiaries named below, to whom I authorize and direct the IAEA to pay at my death any money

standing to my credit.

Required Information of Each Beneficiary

Name

Age

Relationship

Share to be received

1.

%

2.

%

3.

%

I hereby direct, unless otherwise indicated above, that, if more than one beneficiary is named, the share

of the deceased beneficiary or beneficiaries who may predecease me shall be distributed equally among

surviving beneficiaries, or entirely to the survivor. If none survive me, then the entire amount shall go to

my estate.

I hereby specifically reserve the right to revoke or change any beneficiary at any time in the manner and

form prescribed by the IAEA, and without the knowledge or consent of the beneficiary.

Designation of Emergency Contact

I hereby provide my consent to the IAEA to contact the below mentioned person in case of

emergency.

Name:

Telephone number:

(Include country code)

Email address:

………………………… …………………………………………..……

(Date) (Signature)