Application code:
CEEPUS Network Number:
No. of Application: M-
(to be filled in by National CEEPUS Office)
ACADEMIC YEAR: 2005/2006
SCHOLARSHIP APPLICATION FORM
COUNTRY OF ORIGIN:
1. Basic Personal Data:
1.1 Personal Data
academic degree:
first name:
last name:
sex: male female
date of birth:
birthplace:
citizenship:
passport no.:social security no.:
(in your home country)
1.2 Home Address:
street:
ZIP codecity:
country:
phone:fax:
e-mail:
1.3 Address where you want to receive information on your scholarship:
street:
ZIP codecity:
country:
phone:fax:
e-mail:
VALID until: date/month/year
1.4 Home Institution:
university:
faculty:
institute:
street:
ZIP codecity:
country:
phone:fax:
e-mail:
1.5 Current Host Institution: (where applicable)*
university:
faculty:
institute:
street:
ZIP codecity:
country:
phone:fax:
*= only for multiple scholarships within a CEEPUS network
1.6 Knowledge of Languages
0[1] / I / II / III / 0 / I / II / III / 0 / I / II / IIIEnglish / Bulgarian / Polish
German / Croatian / Rumanian
French / Czech / Slovenian
Hungarian / Slovak
Albanian / Serbian / Bosnian
1.7 Field of Study (Index copyright SAIA Slovenska)[2]
/ 140000 / EDUCATION & TEACHER TRAINING / 180000 / FINE & APPLIED ARTS
/ 220000 / HUMANITIES
/ 260000 / RELIGION & THEOLOGY, GENERAL
/ 300000 / SOCIAL & BEHAVIOURAL SCIENCES
/ 340000 / BUSINESS ADMINISTRATION & MANAGEMENT
/ 380000 / LAW
/ 420000 / NATURAL SCIENCES
/ 460000 / MATHEMATICS & COMPUTER SCIENCE
/ 500000 / MEDICAL SCIENCES
/ 520000 / TECHNOLOGY
/ 540000 / ENGINEERING
/ 580000 / ARCHITECTURE & TOWN PLANNING
/ 620000 / AGRICULTURE, FORESTRY & FISHERY
/ 660000 / HOME ECONOMICS (DOMESTIC SCIENCE)
/ 700000 / TRANSPORT & COMMUNICATIONS
/ 780000 / SERVICE TRADES
/ 840000 / MASS COMMUNICATION & INFORM. SCIENCES
/ 890000 / SECURITY & RECREATION
1.8 Local Denomination of your Field of Study (in English)
1.9 Student Progress (students only)
At the time of this application, I am in the semester, and at the planned time of scholarship begin, I will have completed the semester of my studies as specified.
2. Application:
I would like to apply for a month CEEPUS mobility scholarship
As a student teacher
from., to., at the following institution:
2.1 Host Institution
university:
faculty/institute:
street:
ZIP codeCity:
country:
phone:Fax:
2.2 Free-Movers (students)
Free-movers must enclose the following:
- acceptance letter from the desired host institution
- letter from the respective authorities stating exemption from tuition fees
- 2 letters of recommendation (from 2 different professors at the home institution)
- statement of the respective authority at your home institution that your period of study abroad will be recognized
- short description of your period of study abroad
3. Legal Formalities:
- The undersigned herewith confirms that the above data is correct to the best of his/her knowledge, and
- agrees to notify the responsible CEEPUS office of any changes as soon as possible.
- I hereby agree to electronic processing of my personal data
......
datesignature
5. Nomination
5.1 Nomination by Network Coordinator/Partner:
applicant (first & last name):
home university:
After examination of the abovementioned (student´s) application papers, he/she has been nominated for a CEEPUS scholarship.
Signature of Network Coordinator/Partner......
stamp
5.2 Nomination by National CEEPUS Office
applicant (first & last name):
home university:
After examination of the abovementioned (student´s) application papers, he/she has been nominated for a CEEPUS scholarship.
Signature of National CEEPUS Office......
stamp
5.3 Award (by National CEEPUS Office of the host country)
The scholarship has been granted:
from..
to..
number of months:
......
datesignature
......
official stampname of official
1
[1] 0 = not at all, I= basic, II= intermediate, III=fluent. Please note: If you do not mark any box, "0" no competence will be assumed: Please indicate all boxes!
[2] please mark the appropriate box according to your general field of study