SENDINGINSTITUTIONLAN GUAGECOMPETENCE PREVIOUS

ACADEMIC YEAR
Proposed term
of the training:
2016 / 2017
FIELD OF STUDY
(ISCED-F 2013 code):
STUDENT’S
FULL NAME:
(Photograph)
This application should be completed in BLACK in order to be easily copied and/or telefaxed.
S E N D I N G
I N S T I T U T I O N
Name and full address:
Erasmus Code:
Departmental/Faculty coordinator - name
phone number
e-mail
Institutional coordinator - name
phone number
e-mail
L A N G U A G E
Mother tongue:
Other languages
C O M P E T E N C E
Language of instructions at home institution (if different):
I am currently studying
this language
yes
no
I would have sufficient
knowledge to follow lectures
if I had some extra preparation
I have sufficient knowledge
to follow lectures (min. B1+)
yes
no
yes
no
Polish
English
PREVIOUS AND CURRENT STUDY
Recent student’s level of studies:
BSc
MSc
(EQF level 6)
(EQF level 7)
PhD
(EQF level 8)
Number of higher education study years prior to departure abroad:
The attached Transcript of Records includes full details of previous and current higher education study.
Details not known at the time of application will be provided at a later stage.
HOME UNIVERSITY
Coordinator’s
Student’s signature:
signature and stamp:
RECEIVING INSTITUTION - Czestochowa University of Technology
We hereby acknowledge receipt of the application, the proposed learning agreement and the candidate’s Transcript of records.
The above-mentioned student is
Dean’s signature
Date:
Departmental coordinator’s signature
Date:
provisionally accepted at our institution
not accepted at our institution
Institutional coordinator’s signature
Date:
STUDENT APPLICATION FORM
Name
(first name):
Male
(Imię)
Female
SURNAME
(family name):
(NAZWISKO)
BIRTH
Country:
Place:
(urodzony/a)
FATHER
student’s e-mail
Date :
(miejsce)
(kraj)
Name:
dd/mm/yyyy
SURNAME:
(ojciec)
(Imię)
(NAZWISKO)
MOTHER Name:
SURNAME:
(matka)
(Imię)
Home address
(NAZWISKO)
Country:
(adres zamieszkania)
(kraj)
Postal code:
(kod pocztowy)
City:
(miejscowość)
Street:
(ulica)
Number:
(numer)
Passport №
ID №
or National
(EU citizens only):
(non-EU or EU citizens):
(numer paszportu)
(numer dowodu osobistego)
Full name of the most recent completed school:
(nazwa ostatnio ukończonej szkoły)
Graduation date and certificate number:
dd/mm/yyyy
(data i nr świadectwa/dyplomu)
certificate number
Studies starting date (at the home univ.):
dd/mm/yyyy
(data rozpoczęcia studiów)
Date and student’s signature
The part below the line will be filled by the Czestochowa University of Technology officer
Wydział:
WB
WE
WIMiI
WIMPiFS
WIŚiB
WZ
Data rozpoczęcia studiów w PCz:
Kierunek / specjalność:
Semestr:
(data)
Kod USOS:
(czytelny podpis)