<p> UNIVERSITE JULES VERNE PICARDIE</p><p>ERASMUS REGISTRATION FILE FOR UNIVERSITE JULES VERNE PICARDIE</p><p>ACADEMIC YEAR 2010 /2011</p><p>AREA OF STUDY : …………………………………………….</p><p>HOME INSTITUTION</p><p>NAME OF THE HOME INSTITUTION : Department coordinator – Name , phone, fax : ………………………………………………………………………………………………………… e-mail ………………………@……………………………… Institutional coordinator – Name , phone, fax : ……………………………………..– tel…………………………………– fax ………………………. e-mail : </p><p>STUDENT DATA</p><p>Name : date of birth : </p><p>Surname : Place of birth : </p><p>Gender : Male Female Nationality : Permanent address :</p><p>Tel. : email : …………………………@……………… </p><p>WISHES TO BE REGISTERED AT ……………………………………………………………………………………………………………………</p><p>STUDY PERIOD Length Needed NAME OF FACULTY Winter semester Of stay ECTS Spring semester (number credits Year of From To months)</p><p>……………. LANGUAGE PROFICIENCY :</p><p>Mother Language: </p><p>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</p><p>YES NO YES NO YES NO      </p><p>YOUR CURRICULA :</p><p>Which Diploma are you preparing by now : </p><p>How many years have you been studying at your university: </p><p>Have you already been studying abroad ? YES  NO  If yes, in which country/university ? </p><p>APPROVAL OF HOME INSTITUTION </p><p>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 </p><p>Date : Date : </p><p>APPROVAL OF HOST INSTITUTION (UPJV)</p><p>We approve the Erasmus registration of student ………………………………………. (name) Signature of institutional coordinator Date : (Please find here enclosed the learning agreement)</p><p>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 </p>