Outgoing Study Exchange Application Form

2014/2015Page 2

APPLICATION FOR STUDENT EXCHANGE 2014/2015

This form should be completed by all Surrey students planning to study abroad at one of Surrey’s partner universities, including Erasmus partners in Europe.IT MUST BE TYPED.

ABOUT YOU
Family Name: / First Names:
Gender: / Male / Female / Date of Birth:
UG / PG: / Student IDno.
Surrey email: / Personal email:
Mobile no: / Home Telephone :
Place of Birth: / Nationality:
Country of legal permanent residence:
Parents home address:
FINANCIAL SUPPORT
Source of financial support (please tick as appropriate)
Student loan / Parents / Industrial sponsorship
Private means / Government sponsorship
Fee status / Home / Overseas
Are you in receipt of a Surrey Bursary? / If YES, I agree to the IRO checking this information with the Fees & Funding department at Surrey
Are you in the UK on a Tier 4 visa? Yes No
YOUR DEGREE AND QUALIFICATIONS
University Department:
Degree course:
Date of first Enrolment at Surrey:
Name of Personal Tutor:
Name of Course Director:
Name of Erasmus/Exchange Co-ordinator:
GLOBAL GRADUATE AWARD
Are you undertaking the Global Graduate Award (GGA)Yes / No
Language:
What level?
YOUR STUDY DESTINATION
Exchange University of choice (in order of preference) / IRO Office Use only
1.
2.
3.
PROPOSED STUDY EXCHANGE DATES : Please tick appropriate box
1st Semester:
Start date:
End date: / 2nd Semester
Start date:
End date: / Full year
Start date:
End date:
Personal Statement:
Explain your rationale for wishing to study abroad and your choice of the listed partners:
SPECIAL NEEDS (only if applicable)
If you have a special need, tick the box and we will contact you.
(full details will be needed, including medical evidence, if an application is to be made for additional funding)

By submitting this application form you are giving the University of Surrey permission to disclose relevant information to the partner institution in respect of your application.

Studentsignature: ………………………………Date:

Erasmus/Study Abroad Co-ordinatorsignature: …………………………Date:

Please return this form to Sandra Hedley-Boxall, International Relations Office, Senate House, 3rd Floor (B3), Room 17.

If you are an FBEL student, please return this form to: Louise Lawton, 13MS01 Student Exchange Office, Management Building.

DEADLINE FOR RECEIPT OF APPLICATION: 31stJanuary 2014, 5pm