MASARYK UNIVERSITY

FACULTY OF ECONOMICS AND ADMINISTRATION

LIPOVÁ 41a • 602 00Brno - Pisárky • WWW.ECON.MUNI.CZ

APPLICATION FORM

For Exchange Students in Academic Year 2012/2013

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Type of exchange

§  Bilateral Agreement

§  CEEPUS

§  Freemover (a guest student)

§  Other (please specify)

I am applying for ………………………………….

TYpe of Semester

§  Autumn Semester 2012 (17 September 2012 – 13 Feb. 2013)*

§  Spring Semester 2013 (18 February 2013 – 28 June 2013)*

* including exam period

I am applying for …………………………………………………………………

PERSONAL DATA

Family Name:

First Name:

Middle Name(s)

Gender:

Date of Birth (dd/mm/yyyy):

Citizenship:

Passport Number:

ADDRESS

Permanent Address:

Street and Number:

Postal Code and City:

Country:

Telephone Number:

Fax:

E-mail:

Address for Correspondence (If it is different from permanent address):

Street and Number:

Postal Code and City:

Country:

Time Period (from - to):

Parent, Guardian or Next of Kin:

Name:

Street and Number:

Postal Code and City:

Country:

Telephone Number:

Fax:

E-mail:

ACADEMIC BACKGROUND

The Sending Institution

University:

Faculty:

Field of Study:

Year of Study:

Expected Date of Graduation (mm/yyyy):

Full Address:

WWW:

INFORMATION ABOUT YOUR UNIVERSITY’S COORDINATOR

Exchange Coordinator

Name:

Faculty/Department:

Telephone Number:

E-mail:

PRIOR CONTACT

What kind of contact, if any, have you had with the faculty/department(s) in Brno, where you would like to study?

PROPOSED COURSE OF STUDY AT MASARYK UNIVERSITY

Number of months you will spend studying at MU:

Subjects you wish to study (attach the Learning Agreement)

LANGUAGE SKILLS

What languages do you speak?

ANY ADDITIONAL COMMENTS

…………………………………………………………………………….…………………………………………………………………………….…………………………………………………………………………….…………………………………………………………………………….…………………………………………………………………………….…………………………………………………………………………......

APPLICATION FOR HOUSING

Do you wish to apply for accommodation at university residence hall Vinařská?

(Please mark your answer)

YES x NO

Exact rental period from (dd/mm/yyyy):

Exact rental period to (dd/mm/yyyy):

You will be informed during July how to book and pay your accommodation.

Housing conditions and more information about the Vinařská residence hall can be found on: http://www.skm.muni.cz/?lang=en

ORIENATATION WEEK

Do you wish to take part in the orientation week?

More information about the dates and programme can be found on:

http://www.econ.muni.cz/international-relations/

(Please mark your answer)

YES x NO

PLEASE ATTACH A COPY OF YOUR PASSPORT!

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I hereby certify that the data I am submitting with this form is correct.

Student’s signature: Date:

…………………………………………………

Institutional coordinator’s signature: Date:

………………………………………………..

Sending institution’s stamp:

……………………………