Erasmus Student Mobility Agreement
Study Placement – Humanities only
Academic Year: 2013-14
This activity is supported by the Commission of the European Communities within the framework of the LLP Erasmus Programme
PLEASE COMPLETE THIS FORM FULLY IN CAPITAL LETTERS
Application Deadlines: Full year / Semester 1
31 May
Semester 2
30 November
Erasmus Period
Erasmus period abroad
Full year
Semester 1
Semester 2
Personal Details
First Name
Surname
Date of Birth
University ID Number
Sex
Male / Female
Other __________
University Email
Nationality
Alternative Email
Country of permanent
residence
If resident outside the
UK, would you prefer
your grant in Euros?
Yes/No
Permanent address
(to which grant
cheques can be sent)
Fees status
UK
EU
International
Other
Are you eligible for a tuition fees loan from the UK Government?
Yes / No
Have you received an Erasmus grant for a previous period of study or
work? If yes, please give details
Yes / No
Do you have a severe disability, or exceptional special needs, and wish to
apply for additional funding to support your exchange?
If yes, please outline your particular needs on a separate page
Yes / No
Degree Programme Details
Provided that the required level of attainment is reached, the agreed period of study will be recognised as an integral part of the
following University of Southampton degree:
Full Degree Title
Academic Unit
Number of years of university study completed as at 1 Sept 2013
(Postgraduate applicants: please include years of undergraduate study)
Are you studying on an Erasmus Mundus programme?
Yes / No
Study Placement Details
Name of host university
ERASMUS Code
Host country
Length of study placement
(Minimum 3 months)
Language training prior to
study period (please tick)
Language of Instruction
months Start date
(dd/mm/yy)
Erasmus Intensive  Host institution/ 
Language course
country
End date
(dd/mm/yy)
Home institution/  None 
country
J:\Students - outgoing/Forms and letters/13-14 forms/Study (Humanities) – Mobility agreement 13-14.doc
Declaration
Please read the conditions of your Erasmus study placement as listed below. If you fail to comply with these
conditions you will be required to return any Erasmus mobility grant awarded.
1.
I will undertake to carry out the Erasmus study placement (and any approved Intensive Language Course EILC
) as detailed both overleaf and in the separate Learning Agreement. Any amendments or changes to the
Learning Agreement shall be done in writing.
2.
Where possible, the University of Southampton will provide Community financial support for undertaking this
placement (and any approved EILC) under the Erasmus programme of the Lifelong Learning Programme. I
acknowledge that I have been informed of the conditions of the Erasmus mobility grant for study placements. I
accept these conditions and agree:
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
To provide proof of the actual start and end dates of the placement (including any approved EILC).
To confirm my arrival at the host institution in writing.
To supply personal contact details for the duration of the placement on arrival, and to inform the
University of any changes.
To provide the University with a copy of my insurance policy before leaving the UK.
To acknowledge receipt of all grant payments.
To provide proof of full attendance at the end of the placement.
To complete the online final student report on completion of the placement.
To use the Erasmus grant solely for the purpose of covering costs associated with my period of study
abroad
I understand that I may be required to reimburse the grant if the above conditions are not met.
3.
The minimum eligible period for an Erasmus placement is 3 months. The final amount of the grant shall be
determined by multiplying the actual duration of the placement (including any approved EILC) in months and
fractions of months at a rate notified by the National Agency. I understand that I may be required to
reimburse some or all of the grant if the agreed study placement is not completed in full. If I return
early within the first 3 months, I will be required to re-pay in total any grant awarded. I understand that
failure to comply with this clause may lead to legal action to enforce reimbursement. I undertake to inform the
University of Southampton immediately if I wish to leave the placement early.
4.
If I fail to perform any of the obligations arising from this agreement, the University of Southampton is legally
entitled to terminate or cancel the agreement without any further legal formality should I take no action within
one month of receiving notification of the termination by registered letter.
5.
I confirm that I am not in receipt of any other grant from the European Commission LLP budget(such as a
LEONARDO grant) and that, unless I am a student on an Erasmus Mundus programme, I have not been
awarded a Erasmus grant for a study placement in any previous year.
6.
I understand that the grant-giving authorities decline all responsibility for any accident, illness, injury, loss or
damage to persons or property resulting from or in anyway connected with activities which form the subject of
the present contract.
7.
I understand that it is my responsibility to make any insurance arrangements which may be necessary in
respect of the activities for which the grant is awarded.
8.
I understand that whilst abroad I am still registered as a student at the University of Southampton and am
bound by the University regulations, including those regarding academic integrity, personal conduct and
behaviour.
9.
All personal data contained within this agreement will be processed in accordance with Regulation (EC) No
45/2001 of the European Parliament. Such data shall be processed solely for the purposes of the
implementation and follow-up of the agreement between the University of Southampton, the British Council
and the European Commission. I agree to the processing of my personal data for any legitimate purposes
connected with the Erasmus programme as required.
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Signatures
Student
I have read and understood the above conditions in relation to my Erasmus study placement
Name
Signature
______________________________
Date _______________________
Tutor/Study Abroad Office
I confirm that the information given overleaf is accurate and that I have agreed to this student’s Erasmus
study placement at the stated institution as a part of their degree course at the University of Southampton.
Name
__________________________________
Department ____________________________
Title/Role __________________________________
Signature __________________________________
Date
___________________________
Academic Unit Erasmus Co-ordinator
I confirm that this student has been nominated by the department to attend the Erasmus study placement
detailed overleaf.
Name
__________________________________
Department ____________________________
Title/Role __________________________________
Signature ___________________________________
Date
___________________________
To be eligible for an Erasmus grant, you must return this completed form in the first instance to the Study
Abroad Team, Music Office (2/2011), Highfield Campus. They will add the remaining signatures and
forward the form to the International Office, who must receive it by 31 May (Full Year/Semester 1
exchanges) or 30 November (Semester 2 exchanges),
Please note, your full application must also include your Risk Assessment form
Your completed Learning Agreement - to be signed by the Erasmus co-ordinator at Southampton
before the start of your exchange, then signed by your host university and sent to the Study Abroad
Team either before the start of your exchange or within two weeks of arrival
J:\Students - outgoing/Forms and letters/13-14 forms/Study (Humanities) – Mobility agreement 13-14.doc