Application Form 2015 - 2016

Course applied for

Personal Details

Last name / Family name: / Title: Mr, Miss, Mrs
First names / given names : (As shown on passport)
Date AND Place of Birth :
Permanent Address :
Correspondence Address:
Mobile phone : Telephone:
E mail :

For MOD ART use ONLY

Date Application Received:
Fee status : EU International Interview :
Unconditional offer :
Conditional offer :
Reject : applicant not suitable for course:

Nationality Status

Country of birth :
(As shown on passport)
Country of permanent residence:
Visa conditions :
Entry : (to be filled in once accepted)
Departure date:

Educational qualifications :

University, School, College Name Town / Degree qualification level / Subject (s) / Dates from & to

Please include copies of qualifications and transcripts. English language qualifications:

Other foreign languages including French level:

Internships, work experience associated with studies:

Employment history :

Please include up to date CV.

References :

Please provide the names and contact details of two referees who have known you academically or professionally. To be sent separately.

Name: / Name:
Position / Position
Organisation: / Organisation:
Address: / Address:
Post Code / Post Code
Country: / Country:
Telephone: / Telephone:
Fax: / Fax:
eMAIL: / eMAIL:
Relationship to you: / Relationship to you:

Personal statement : Continue on a separate sheet if required.

Your reasons for choosing the course; the work experiences which have helped you in your choice of a career in Fashion and your plans for the future.

Declaration :

I confirm that the information given on this form is correct and complete, and that I have completed all sections myself.

Signature of applicant :

Date :

STUDY ABROAD PROGRAMMES

Institut International Privé des Arts et de la Mode
1 rue Bouvier – 75011 PARIS – France –
Tél: +33(0) 1 58 39 36 70 – Fax: +33(0) 1 40 09 15 14
www.mod-art.org / email: / 1