STUDENT APPLICATION FORM
Academic Year 20../20..						
Photo of applicant

for studies:			for placement:	

This application should be completed in BLACK in order to be easily copied and/or faxed.

SENDING INSTITUTION

Name and full address: ………………………………………………………………………………………………

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Department coordinator - name, telephone and fax numbers, e-mail: ……... ……………………………………….

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Institutional coordinator - name, telephone and fax numbers, e-mail: ……………………………………………….

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STUDENT’S PERSONAL DATA  (to be completed by the student applying)

Family name: ………………………………….         First name (s): ……………………………………..

Date of birth:…………………………………..         Sex: ………. 

Citizenship: ……………………………………

Address in home country:…………………………………………………………………………………..

……………………………………………………………………………………………………………...

Tel.: …………………………………………….

E-mail: ………………………………………….

PERSON(S) TO CONTACT IN CASE OF EMERGENCY

Name and relationship to applicant: …………………………………. ….………………………………..

Address:……………………………………………………………………………………………………

Tel.: …………………………………………….

E-mail: ………………………………………….

RECEIVING INSTITUTION:

Institution	Country	Period of study/placement	Duration of stay (months)	N° of expected ECTS credits	
		from	to			

Name of the study course/practical training:   ………………………………………………………………………
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Knowledge, skills and competences to be acquired: …………………………………………………………………..
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Briefly state the reasons why you wish to study/practice abroad?
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LANGUAGE COMPETENCE

Mother tongue: …………………          Language of instruction at home institution (if different): ………………………	
Other languages	I am currently studying this language	I have sufficient knowledge to follow lectures/ participate in training	I would have sufficient knowledge to follow lectures/ participate in training if I had some extra preparation	
	yes	no	yes	no	yes	no	
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WORK EXPERIENCE RELATED TO CURRENT STUDY / TRAINING PLANNED (if relevant)

Type of work experience	Firm/organisation	Dates	Country	

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PREVIOUS AND CURRENT STUDY

Diploma/degree for which you are currently studying: ……………………………………………………………..

Number of higher education study years prior to departure abroad: ………………………………………………..

Have you already been studying / working abroad?                Yes             No 

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 be provided at a later stage.	

Do you wish to apply for a mobility grant to assist towards the additional costs of your study/training period abroad? 
Yes           No 	

RECEIVING INSTITUTION	
We hereby acknowledge receipt of the application, the proposed learning agreement/training agreement and the candidate’s Transcript of records.	
The above-mentioned student is                       

Departmental coordinator’s signature

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Date: ………………………………………	provisionally accepted at our institution
not accepted at our institution

Institutional coordinator’s signature

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Date: ……………………………………………...