Incoming Student Application Form

INCOMING STUDENT APPLICATION FORM

ACADEMIC YEAR 2017- 2018

FIELD OF STUDY: ......

Type of mobility (internship or courses): ......

/!\Note that to be considered, your application must add your "Learning agreement”

STUDENT PERSONAL DATA

Name:First name:PHOTO

Date of birth:Place of birth:

Age:Sex: M/FNationality:

ID or passport number:

Current address:

Tel.:Fax :Email :

Mobile:

Permanent address (if different):

PREVIOUS AND CURRENT HIGHER EDUCATION STUDY

Degree programme you are currently studying for:

Number of higher education years prior to departure abroad:

Have you already studied abroad?

If so when? At which institution?

Please attach transcript of records with full details of previous and current higher education study. Details not known at the time of application will be provided at a later stage.

What is your level of FRENCH (minimum B1-B2 required)?

What is your level of English?

STUDY PERIOD AT RECEIVING INSTITUTION

Duration: ….. monthsfrom:to:

Number of expected ECTS:

COMPLEMENTARY INFORMATION

Do you have any health problem needing special care/attention? If so, please indicate which.

RECEIVING institution ERASMUS ID Code B MONS 23

Name : HEPH-Condorcet

Address : Chemin du Champ de Mars, 177000 MonsBelgium

Institutional coordinator

Name :VERBEKE Anne

Tel. :+32 (0)71 60 93 36Fax : +32(0)65 382 626Email :

Departmental coordinator

Name :

Tel.:/Fax : /Email :

ECO.006.DOC.002/1

SENDING institution

Name:

Address:

Institutional coordinator

Name:

Tel.: Fax:Email:

Departmental coordinator

Name:

Tel.:Fax:Email:

STUDENT

Signature:

Date:

Sending institution

Departmental coordinatorInstitutional coordinator

Signature:Signature + stamp:

Date : Date :

Receiving institution

We hereby acknowledge receipt of the candidate’s application and transcript of records and declare that the above-mentioned student is accepted.

Departmental coordinator Institutional coordinator

Signature:Signature:

Date :Date :

______
Please fill in this form (CAPITAL LETTERS), sign, get signed by your institution coordinators

and send back by postto:

HEPH-Condorcet

c/o MrClaire AVRIL,

International coordinator

Boulevard Roullier 1, 2° étage AC00

6000 Charleroi,

Belgium

Or by e-mail to:

(PDF Version)

ECO.008.DOC.002/1