ERASMUS STUDY EXCHANGE APPLICATION FORM
Academic Year:
…………………………………
STUDENT’S ACADEMIC DETAILS:
Student Name:
………………………………………………………………….
Student ID No:………………………….
Department:
………………………………………………………………….
Course of Study:
………………………………………………………………….
Current Year of Study at CIT: ………………………
State briefly the reasons why you wish to study abroad:……………………………….
…………………………………………………………………………………………..
…………………………………………………………………………………………..
…………………………………………………………………………………………..
STUDENT’S PERSONAL DATA:
Family Name: …………………
First Name(s):…………………………...
Date of Birth: …………………
Nationality:……………………………...
Term Address:…………………
Permanent/Home Address (if different):
…………………………………
…………………………………………..
…………………………………
…………………………………………..
Mobile No:…………………….
Home Tel. No.:………………………….
Email address: ……………………………
Disability/Special Needs (Physical/other disability or medical condition requiring
special arrangements or facilities):
………………………………………………………………………………………………….
………………………………………………………………………………………………….
Name and contact details of person at home whom we can contact in case of
emergency:
………………………………………………………………………………………………
………………………………………………………………………………………………
DETAILS OF HOST INSTITUTION (WHERE YOU WISH TO STUDY)
Name of Host Institution: …………………………………………….
Duration of Exchange:
From:……………………
To:………………………...
Type of Study (please circle as appropriate):
Course Work
Project Work
Practical Training
Will you be taking exams at the host institution?
YES/NO
LANGUAGE COMPETENCE (please consult the Council of Europe’s Common
European Framework of Reference for Languages and circle the relevant
competence code)
French:
A1
A2
B1
B2
C1
C2
German:
A1
A2
B1
B2
C1
C2
Spanish:
A1
A2
A3
B2
C1
C2
Italian:
A1
A2
A3
B2
C1
C2
Other (please specify): ……………..
Level:
A1
A2
A3
B2
C1
C2
Student’s Signature: …………………………..
Date: ………………
CIT Academic Coordinator’s Signature: ………………….
Date:……………….