(Photograph)
ACADEMIC YEAR
2003-2004
FIELD OF STUDY:
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This application should be completed in BLACK in order
to be easily copied and/or telefaxed.
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SENDING INSTITUTION Name and full
address:....................................................................................... ........................................................................................................................... ........................................................................................................................... Department
coordinator - name, telephone and telefax numbers, e-mail box ...... ...................................................................................................................…..... ........................................................................................................................... ........................................................................................................................... Institutional
coordinator - name, telephone and telefax numbers, e-mail box....... ........................................................................................................................... ........................................................................................................................... ........................................................................................................................... |
STUDENT’S PERSONAL DATA
(to be
completed by the student applying)
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Family name: ................................... Date of
birth: ................................... Sex:
.........Nationality:...................... Place of Birth:
.................................. Current
address:...........................…. ......................................................... ......................................................... ......................................................... Current
address is valid until: .......... Tel.: |
First name (s): .............................. Permanent
address (if different): ........ .......................................................... .......................................................... .......................................................... .......................................................... Tel.:
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LIST OF INSTITUTIONS WHICH WILL RECEIVE THIS APPLICATION FORM (in order
of preference):
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Institution |
Country |
Period of study from
to |
Duration of stay (months) |
N° of expected ECTS credits |
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1................. 2................. 3................. |
................ ................ ................ |
........... ........... ........... |
.......... .......... .......... |
................ ................ ................ |
..................... ..................... ..................... |
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Name of student:............................................................................................. Sending
institution:..…....................................Country:.................................. |
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Briefly state the reasons why you wish to study
abroad ? ....................................................................................................................... ....................................................................................................................... ....................................................................................................................... |
LANGUAGE COMPETENCE
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Mother
tongue: ................ Language of instruction
at home institution (if different): ........................ |
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Other languages |
I am currently studying this language |
I have sufficient knowledge to follow lectures |
I would have sufficient knowledge to follow lectures
if I had some extra preparation |
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yes |
no |
yes |
no |
yes |
no |
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.................. .................. .................. |
o o o |
o o o |
o o o |
o o o |
o o o |
o o o |
WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant)
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Type of work experience ........................... ........................... |
Firm/organisation ..................... ..................... |
Dates .................. .................. |
Country ....................... ....................... |
PREVIOUS AND CURRENT STUDY
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Diploma/degree for which you are currently studying: ................................................................................ Number of
higher education study years prior to departure abroad: ................................................................................ Have you
already been studying abroad ?
Yes o No
o If Yes, when
? at which institution ? ..............................................................…............... The attached Transcript
of records includes full details of previous and current higher education
study. Details not known at the time of application will provided be at a
later stage. |
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Do you wish to
apply for a mobility grant to assist towards the additional costs of your
study period abroad? Yes o No o |
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RECEIVING
INSTITUTION |
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We hereby
acknowledge receipt of the application, the proposed learning agreement and the
candidate’s Transcript of records. |
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The above-mentioned student is o
o Departmental coordinator’s signature .................................................... Date:............................................ |
provisionally accepted at our institution not accepted at our institution Institutional coordinator’s signature ...................................................... Date:.............................................. |
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