APPLICATION FOR STUDENT EXCHANGE
ACADEMIC YEAR 2010/ 2011
This application should be completed in BLACK in order to be easily copied and/or faxed.
STUDENT’S PERSONAL DATA
Family name: .......................................................
Permanent address (if different): ....................................
First name (s): .....................................................
..........................................................................................
Date of birth: .......................................................
..........................................................................................
Place of Birth: .....................................................
..........................................................................................
Sex: ............... Citizenship: ...................................
..........................................................................................
Current address: ..................................................
Tel.: .................................................................................
..............................................................................
..............................................................................
Fax: .................................................................................
E-mail: ............................................................................
Please indicate if you are a student with special
needs:
Yes 
No 
PREVIOUS AND CURRENT STUDY
University and faculty you are currently studying at: ......................................................................................
Your current field of study: .........................................................................................................................
Diploma/degree for which you are currently studying: ....................................................................................
Number of higher education study years prior to departure abroad: ................................................................
Have you already been studying abroad ?
Yes 
No 
If Yes, when and at which institution? .................................................................................................................
WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant)
Type of work experience
Firm/organization
Dates
Country
..............................................
..............................................
.............................................
.............................................
.............................
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I WISH TO APPLY FOR A STUDENT EXCHANGE AT:
First choice
Institution and country
…………………………………………..
Term (spring/winter)
………………………………………….
Intended date of:
arrival
departure
………………
……………..
Duration of stay
(months)
…………………………….
Courses you would like to attend and/or description of other academic activities (research, writing diploma essay)
…………………………………………………………………………………………………………………………………………………………………………….
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Second choice
Institution and country
…………………………………………..
Term (spring/winter)
………………………………………….
Intended date of:
arrival
departure
………………
……………..
Duration of stay
(months)
…………………………….
Courses you would like to attend and/or description of other academic activities (research, writing diploma essay etc.)
…………………………………………………………………………………………………………………………………………………………………………….
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Third choice
Institution and country
…………………………………………..
Term (spring/winter)
………………………………………….
Intended date of:
arrival
departure
………………
……………..
Duration of stay
(months)
…………………………….
Courses you would like to attend and/or description of other academic activities (research, writing diploma essay)
…………………………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………………….
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LANGUAGE COMPETENCE
Mother tongue: ................... Language of instruction at home university (if different): ..................................
Other languages
..........................
..........................
..........................
I am currently studying
this language
yes



no



I have sufficient knowledge
to follow lectures
yes



no



I would have sufficient knowledge to
follow lectures if I had some extra
preparation
yes



no



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APPENDIXES
Appendixes to be submitted with this application:
1) a CV in English (available at: http://europass.cedefop.europa.eu/europass/preview.action
2) a motivation letter in English
3) a transcript of records (of all the grades) in Croatian
4) a certificate of language skills of the language of instruction at the host university (students studying a
language do not need it)
Date: ..................................................
Signature: ...............................................................
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