Universite Jules Verne Picardie

UNIVERSITE JULES VERNE PICARDIE

ERASMUS REGISTRATION FILE FOR UNIVERSITE JULES VERNE PICARDIE

ACADEMIC YEAR 2010 /2011

AREA OF STUDY : …………………………………………….

HOME INSTITUTION

NAME OF THE HOME INSTITUTION : Department coordinator – Name , phone, fax : ………………………………………………………………………………………………………… e-mail ………………………@……………………………… Institutional coordinator – Name , phone, fax : ……………………………………..– tel…………………………………– fax ………………………. e-mail :

STUDENT DATA

Name : date of birth :

Surname : Place of birth :

Gender : Male Female Nationality : Permanent address :

Tel. : email : …………………………@………………

WISHES TO BE REGISTERED AT ……………………………………………………………………………………………………………………

STUDY PERIOD Length Needed NAME OF FACULTY Winter semester Of stay ECTS Spring semester (number credits Year of From To months)

……………. LANGUAGE PROFICIENCY :

Mother Language:

Competences I am studying I have enough competences an extra courses should In host language it by now to understand the courses allow me to understand the courses

YES NO YES NO YES NO      

YOUR CURRICULA :

Which Diploma are you preparing by now :

How many years have you been studying at your university:

Have you already been studying abroad ? YES  NO  If yes, in which country/university ?

APPROVAL OF HOME INSTITUTION

The student……………………………………………. is allowed to register at an Erasmus student at UNIVERSITE DE PICARDIE JULES VERNE… Erasmus code : F AMIENS 01 for  Winter Semester 10/11  Spring Semester 11  Year 10/11 in faculty of ………………………………………………………………………. Signature of department (pedagogical) coordinator Signature of institutional coordinator

Date : Date :

APPROVAL OF HOST INSTITUTION (UPJV)

We approve the Erasmus registration of student ………………………………………. (name) Signature of institutional coordinator Date : (Please find here enclosed the learning agreement)

Contact : Direction des Affaires Internationales - Université de Picardie Jules Verne Chemin du Thil - 80025 AMIENS CEDEX 1 - France www.u-picardie.fr Erasmus code: F AMIENS 01 mail: [email protected] Tel. : + 33 (0) 22 82 79 90 - Fax : + 33 (0) 22 82 72 47