1.1_WZÓR_Application_form - MEiL

KEY ACTION 1 – MOBILITY OF INDIVIDUALS
HIGHER EDUCATION STUDENTS
ERASMUS +
STUDENT APPLICATION FORM
(Photograph)
ACADEMIC YEAR 2016 /20 17
FIELD OF STUDY:
Aerospace Engineering
Lotnictwo i Kosmonautyka
Power Engineering
Nuclear Power
Engineering
Automatic Control
and Robotics
Automatyka i
Robotyka
Mechanika i Budowa
Maszyn
Energetyka
Energetyka Jądrowa
Inne (wpisz)
This application should be completed in BLACK in order to be easily copied and/or telefaxed.
SENDING INSTITUTION, FACULTY
Name and full address: Warsaw University of Technology; Faculty of Power and Aeronautical Engineering
Politechnika Warszawska, Wydział Mechaniczny Energetyki i Lotnictwa
Tutor - name, telephone and telefax numbers, e-mail box : Prof. Elżbieta Jarzębowska
(aerospace)- Faculty Erasmus Coordinator; :+ 48 22 234 60 29; [email protected]
dr inż. Nikołaj Uzunow (power & nuclear); Faculty Erasmus Coordinator; + 48 22 234 52 97 ;
[email protected]
Dean - name, telephone and telefax numbers, e-mail box Prof. Jerzy Banaszek / Prof. dr hab. inż. Jerzy
BANASZEK; [email protected] tel. + 48 22 621 53 10 fax: +48 22 625 73 51
STUDENT’S PERSONAL DATA
(to be completed by the student applying)
Family name: Kowalski .................................
Date of birth: . 11/03/1989.......................................
Sex: . Male .......Nationality:........ Polish ...............
Place of Birth: .......... Kraków ..............................
Current address: . ul. Erasmusa 3 mieszkania 4, 00-009
Kraków .............................
First name (s): Jan Maciej
........................................................
Permanent address (if different): ...........
................
..............................................................................
..............................................................................
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Current address is valid until: ....
16/05/2020.................
Tel.: .......... 555-666-7777........................................
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Tel.: .................
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PREVIOUS PARTICIPATION IN ERASMUS
YES/ NO
Previous participation in Erasmus at the same level of study
Study Cycle: FIRST
SECOND
THIRD
Study (Number of months):……………………………………………………………….
Placement (Number of months):.........................................................................................
LIST OF INSTITUTIONS WHICH WILL RECEIVE THIS APPLICATION FORM (in order
of preference):
Institution
Country
Period of study
from
1. Univeristy of Genova
2.
................................
3. .
.................................
... Italy .........
....
......
......
.....
01/10/201
6..
..
to
Duration of
stay
(months)
20/02/20
17.
.
...
...
...
. 5 ......
...
...
...
....
N° of expected credits
(hours)
30ECTS/
60 ECTS
........................
........................................
.........................................
Name of student: ........................................ Jan Kowalski ...............................................................................
Sending institution, Faculty: Faculty of Power and Aeronautical Engineering/ WUT/ Wydział Mechaniczny
Energetyki i Lotnictwa/ Politechnika Warszawska
Country: Poland/ Polska
Briefly state the reasons why you wish to study abroad ? I would like to extend my knowledge connected with the
Automatic Control and Robotics programme and improve my knowledge of Italian.
...........................................................................................................................................................................
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LANGUAGE COMPETENCE
Mother tongue: .. Polish ... Language of instruction at home institution (if different): ...... English............
Other languages
I am currently studying
this language
yes
I have sufficient
knowledge to follow
lectures
no
yes
I would have sufficient knowledge to
follow lectures if I had some extra
preparation
no
yes
no
..... English ......
.... Italian .....
..... German ........
WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant)
Type of work experience
Firm/organization
Dates
Country
Robot preparing specialist
Firm ABC
01/07/2015-30/07/2015
Poland
Assistant
Firm DBC
01/08/2015-30/08/2015
Germany
PREVIOUS AND CURRENT STUDY
Diploma/degree for which you are currently studying: ............ Master in Engineering
............................................
Number of higher education study years prior to departure abroad: .....................
Have you already been studying abroad ?
Yes
No
If Yes, when ? at which institution ? .....
.................................
.......................................................
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.
Do you wish to apply for an ERASMUS + mobility grant to assist towards the additional costs of your
study period abroad?
Yes
No
RECEIVING
INSTITUTION,
Department:
Univeristy
of
Genova/
Faculty
of
Engineering
............................................................................
We hereby acknowledge receipt of the application, the proposed learning agreement and the candidate’s
Transcript of records.
The above-mentioned student is
provisionally accepted at our institution
not accepted at our institution
Tutor’s signature
Dean’s signature
..............................................................................
Date: ....................................................................
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Date :................................................................................