EXCHANGE PROGRAMME
STUDENT MOBILITY FOR STUDY
STUDENT APPLICATION FORM
(Photograph)
ACADEMIC YEAR 2015/2016
FIELD OF STUDY:
This application should be completed in BLACK in order to be easily copied and/or faxed.
SENDING INSTITUTION
Name and full address of a home institution:
Institutional contact person at a home institution (name, phone, fax, e-mail):
Departmental contact person at a home institution (name, phone, fax, e-mail):
STUDENT’S PERSONAL DATA
Family name:
Gender: F
First name (s):
Place of birth:
Date of birth:
Tel.: +
M
Nationality:
e-mail:
Postal address:
Permanent address (if different):
Street, house number
Street, house number
City
City
Postal Code
Country
Postal Code
Country
Current address is valid until:
RECEIVING INSTITUTION
Institution
Country
Period of study
from
Palacký University Olomouc
to
Duration of
stay
(months)
CZ
Name of student:
Sending institution:
Country:
N° of expected ECTS credits
Briefly state the reasons why you wish to study abroad:
LANGUAGE COMPETENCE
Mother tongue:
Other languages
Language of instruction at home institution (if different):
I am currently studying
this language
I have sufficient
knowledge to follow
lectures
I would have sufficient knowledge
to follow lectures if I had some
extra preparation
yes
yes
yes
no
no
no
WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant – not necessary)
Type of work experience
Firm/organisation
Dates
Country
PREVIOUS AND CURRENT 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 ? At which institution ?................................................................................................................
RECEIVING INSTITUTION:
We hereby acknowledge receipt of the application and the proposed learning agreement.
The above-mentioned student is


provisionally accepted at our institution
not accepted at our institution
Responsible Person´s signature
Institutional coordinator’s signature
...........................................................................
Date: .................................................................
......................................................................................
Date ..............................................................................
Send this application with enclosed documents: Learning Agreement, Housing Request Form, Orientation
Week Registration Form, Transcript of Records (optional)
by e-mail: stepanka.bublikova@upol.cz
Deadlines:
(Incoming student coordinator)
Fall semester / whole academic year – May 31
Spring semester – October 31