Comune Di Concordia Sulla Secchia

Comune di Medolla Application Form for the LEONARDO DA VINCI-Project Please fill in with typewriter. Use the language of the country you chose or English. If there is not enough place use a separate page. Personal details Full name: In case of emergency contact: Street: Zip Code, town: Name: Country: Tel: Tel.: Street: email: Zip Code, town: Fax: Country: Nationality: Date of birth: Sex: Position about the national military/civil service :

Education/Professional experience Which school education/degree do you have ? Which vocational training do you have? What is your job title? At the moment you are * employed as at * unemployed since Which professional experience do you have ?

Have you been abroad for longer (exchange, practical training etc.)?

In which professional field would you like to do the practical training? (Please give examples) 1)

3) Foreign languages You can not at all a little bit mediocre/ Fluently communicate in above average English German Italian Hungarian Spanish French ………

Expectations/Plans Please describe what you expect from a practical training abroad.

What are your career plans after the project?

What wishes, hopes and fears do you have concerning this project?

Why do you think, apart from your professional qualification, you fit into the project?

We need the following details for your stay abroad Do you smoke? yes no Are you vegetarian? yes no Do you have a driving licence? yes no Are there any activities that you cannot perform due to a handicap (e.g. allergies etc.)? ......

Herewith I assure that all given details are true. Autorizzo al trattamento dei dati ai sensi del D.lgs. n°196/03 ______Date, Signature

ONLY IF REQUIRED BY THE PROJECT CO-ORDINATOR, please enclose in your application copies of certificates and references (no originals).