<p> Application form Academic year 2017/2018</p><p>Fill in all the required information carefully in CAPITAL LETTERS and check the boxes of your choices</p><p>Personal information </p><p>Family name: ...... Married name: ...... First name(s): ……………………… </p><p>BIRTH Date: |__|__| / |__|__| / |_1_|_9_|__|__| State/Region/Country : …………………………………………………………….. Town: ………………………………………………………………………………………………………………………….  Male  Female NATIONALITY FAMILY STATUS COUNTRY : …………….…………  1 - Single  2 – With partner, no children</p><p> 3 - Single with children  4 – With partner, children Number of children : …………  DISABILITY </p><p>1st REGISTRATION IN FRANCE </p><p>In French higher education (BTS and CPGE included) year |__|__|__|__| / |__|__|__|__| In a French university year |__|__|__|__| / |__|__|__|__| Name of the university :...... At the University of Bordeaux (IUT-ESPE-IEP-IAE included) year |__|__|__|__| / |__|__|__|__|</p><p>FRENCH « BACCALAURÉAT » or EQUIVALENT</p><p>Type |__|__|__| Distinction : TB B AB P Year of completion |__|__|__|__| / |__|__|__|__| School, Department (for France only): …………………..…………….………………………………. ou :  Foreign equivalent diploma (0031) </p><p>Addresses of the applicant ADRESSES Regular postal address (outside university: parents / home) Number – Street – Building, etc...... Postal code: |__|__|__|__|__| Town:...... Country:...... Telephone: ...... </p><p>Accommodation for the academic year 2017-2018:  1 Hall of residence  4 Parental home  5 Personal home Number – Street – Building, etc...... Postal code: |__|__|__|__|__| Town:...... Country:...... Telephone: ...... ……..………. </p><p>E-mail: ……...……………………………………………………………….. SOCIO-PROFESSIONAL SITUATION APPLICANT:………..…………………………...... </p><p>MOTHER:………………………………………………………. FATHER:………………………………………………………..</p><p>Professional activity of the applicant: (please provide a work certificate)…………………………………………………………………………….</p><p>1  Full time 2  Part-time <150h/90 days 3  Part-time >= à 150h/90jours</p><p>MAIN FINANCIAL AIDS</p><p>F  French government international grant holder W  AUF grant for international students G  Mobility grant K  Wage H  Foreign government holder (without exemption) 3  Financial resources of the partner Ü  The National Emergency Assistance Fund (FNAU) 5  Financial resources of parents</p><p>PROGRAMME D’ÉCHANGE INTERNATIONAL 9  Erasmus + (mobility) P  Erasmus Mundus (diploma course) V  Other programs funded by the EU S  Erasmus Mundus A2 5  Other programs and bilateral agreements</p><p>Country: …………………………………………….. University/school:…………………………………………….</p><p>Application LAST INSTITUTION ATTENDED (year of the most recent enrolment)</p><p> 00 – University  03 – Business school  13 – School of architecture  19 – Teacher training school  04 – Engineering school  15 –Other  18 – Paramed. & social school  05 – Private institution  17 – Correspondence courses  99 – No institution  06 – Arts/Culture higher education institution  10 – Foreign higher education institution Name of institution:………………………………………………..</p><p>Department (France only) |__|__|__| OR Country…………………………. ………….Year of attendance |__|__| / |__|__| PREVIOUS YEAR SITUATION (2015/2016) A  French secondary school H  French university R  Foreign higher education institution (included correspondent courses) I  Teacher training school S  Other E  Engineering school J  Business school T  Out of school and never enrolled in G  Higher education institution K  Other (paramedical excluded) higher education (correspondence) Q  Foreign secondary school U  Out of school but previously enrolled in higher education </p><p>Name of institution: …………………………………………..………Department (France only)/country………..…...……</p><p>LAST COMPLETED DEGREE</p><p>Title: ……………………………………………………………………………………………………………………………. </p><p>Institution : ………………………………….. Year |__|__| / |__|__| Departement (France only)|__|__|__| </p><p>Country: ………………………………………… Social protection and optional rights SOCIAL SECURITY AFFILIATION (medical insurance)</p><p>Age of the application on August 31st, 2018 PARENTS 20 years old From 21 to 28 years old Place an X in the box corresponding to your situation (born between 01/09/96 and 31/08/97) (born between 01/09/88 and 31/08/96)</p><p> Private sector employees or equivalent, wage-earner, farmers, civil servants, contracted medical practitioners Affiliation : YES Affiliation : YES or assistants, registered job seekers, collectivity agent, Subscription : YES Subscription : YES artists, authors, “Banque de France” employees</p><p> Self-employed persons (craftsmen merchants, industrials, Affiliation : YES Affiliation : YES non-contractual liberal professions) special regime of Subscription : YES Subscription : YES international officials</p><p> Derogatory regimes (merchant marine, port of Affiliation : NO Affiliation : YES Subscription : NO Bordeaux, Théâtre national de l’Opéra, Comédie Subscription : YES Française, Assemblée nationale) (join a certificate)</p><p>Affiliation : YES Affiliation : YES  Students with parents living and working abroad Subscription : YES Subscription : YES</p><p>NAME and FIRST NAME of father:……………………………………………Date of birth: |__|__|__|__|__|__| NAME and FIRST NAME of mother:………………………………………..... Date of birth: |__|__|__|__|__|__|</p><p>Chosen security centre for payment of social security benefits (even if you do not subscribe to any health mutual),  LMDE  VITTAVI – Réseau Emevia </p><p>CASES OF NON AFFILIATION:</p><p>Place an X in the box corresponding Situation of the applicant Please provide : to your situation You are enrolled in another higher education Certificate of enrolment showing payment of  contribution already paid in another institution and have already paid for student social student social security higher education institution security  you benefit from social coverage thanks You are married and you benefit from your Certificate of social security for the academic to your partner’s work partner’s social security year (from September 1st to August 31st) Your parents are French employees of an Certificate of social security for the academic  Parents are international officials international organization year (from September 1st to August 31st) You are from a EU country and benefit from social  Applicant from a country of the EU E106 certificate or the European Health Insurance security for the academic year (from October 1st to other than France and holder of the Card valid until August 31st, 2017 European Health Insurance Card September 30th) You work more that 150h/90 days and you are  Other social security regime covered by your contract without interruption Copy of contract and last three pay slips. during the whole year INSURANCE (school, extracurricular, traineeships) covering the academic year 2017-2018</p><p>Name of your insurance company…………………………………………………………………..… (join a certificate) I have no insurance, I subscribe to:  LMDE  VITTAVI – Réseau Emevia</p><p>In: ……………….……………..……. Date: ……… / …….. / ………….. </p><p>Signature of the applicant:</p>