/ EXCHANGE STUDENT
(Non Degree-Seeking Student)
APPLICATION FORM
Academic Year 2016/2017 / Attach a recent photo here

Please tick the relevant boxes in each of three categories below:

Non paying/tuition-free Exchange (English Track)

Non paying/tuition-free Exchange (Bachelor)

Non paying/tuition-free Exchange (ICTB)

Study Abroad (fee paying- student)

Fall Semester (September 2016 to December 2016)

Spring Semester (January 2017 to June 2017)

Student from a Partner University (Tuition Fees waived)

Student from a non-Partner University (Free-Mover)

This application should be typed to avoid errors.

1.STUDENT’S PERSONAL INFORMATION

Gender (M / F)
First Name
Family Name
Nationality / Mother Tongue
DOB (dd/mm/yyyy) / Place of Birth
Phone + Country Code / Cell Phone
Permanent Address
Zip Code, City, Country
PersonalEmail Address (no university address)

2. SENDING INSTITUTION

Name of University
Address
Zip Code, City, Country
INTERNATIONAL COORDINATOR
First Name
Family Name
Position/Department
Phone (+ Country Code)
Email Address

3. EDUCATION (after college)

2015-2014
2014-2013
2013-2012
2011-2010
2010-2009

4. LANGUAGE PROFICIENCY

Mother Tongue: Language of instruction (if different):
European Level(A, B or C) / Test (TOEFL, TOEIC, IELTS…) / Score
English
Other Languages
French: please tick the appropriate box
If you have any doubts, test yourself:
Level / Number of Hours / European Level
Equivalent / Tick
Total beginner / 0 / A0
Beginner / 0-20 / A0+
Lower intermediate / 20-60 / A1-
60-120 / A1
120-150 / A1+
Intermediate / 150-200 / A2-
200-250 / A2
250-300 / A2+
Upper intermediate / 300-400 / B1
Advanced / 400+ / B2

6. HEALTH INSURANCE

European students: a copy of the European Health Insurance Card has to be provided. The liability insurance is compulsory and can be purchased here:
Non-European students:French Social Security coverage is compulsory. You will be sent an URL, which will enable you to pay the 215€ fees. (Academic year 2015/2016)
The liability insurance is also compulsory,with “assistance etudiants” It costs around 30€, and can be purchased here:

6. HOW DO YOU INTEND TO FINANCE YOUR LIVING EXPENSES?

Student’s Name and Signature:

Date:

7. EXCHANGE CONFIRMATION

Sending Institution:
We confirm that the above-mentioned student has been nominated by our Office and is enrolling in the English Track:
for exchange (tuition fees waived)
for study abroad (tuition fees not waived)
Date
International Coordinator
Name:
Position:
Signature:
(Stamp the document please) / Receiving university: Telecom Ecole de Management
We hereby acknowledge receipt of the student’s application.The above-mentioned student is:
accepted
rejected
Date
Isabel-Mary Morgan
Student Exchange Coordinator

Checklist of the documents to be submitted

Application Form duly signed by the student and coordinator

Recent photo (passport size) scanned or attached to the first page of this form

Copy of passport for non-European citizens or copy of the Identity Card for European citizens

Learning Agreement

Official Transcripts of the last 2 years (in English or French)

Resume

Cover Letter

Proof of Health Insurance

Proof of Liability insurance

APPLICATION TO BE SENT TO

Please forward your complete application to your international coordinator, who will:

Mail it to:

Isabel-mary.morgan

Student Exchange Coordinator

TélécomEcole de Management

International Office, DIR A07

9, rue Charles Fourier
91011 Evry Cedex, France

Or email it to:isabel-mary.morgan @telecom-em.euin ONE pdf file.

APPLICATION DEADLINES

Applications for fall semester to be received before April 30th

Applications for spring semester to be received before October 30th

1/3