Tomsk Polytechnic University
Томский Политехнический Университет
Application form for incoming exchange students
Аппликационная форма для академических обменов
Academic year/ Учебный год 2010/11
SENDING INSTITUTION
RECEIVING INSTITUTION
Направляющий университет
Принимающий университет
Sending University/ Название университета
_______________________________________
Receiving University/ Название университета
Tomsk Polytechnic University
_______________________________________
Address/ Адрес
_______________________________________
_______________________________________
Department/ Факультет
_______________________________________
_______________________________________
Major/ Специальность
_______________________________________
_______________________________________
Academic supervisor/coordinator/
Address/ Адрес:
30, Lenin Prospect, Tomsk,
Russia, 634050
Phone/Fax/Тел/Факс: + 7 (3822) 56 32 68
Fax /Факс: + 7 (3822) 56 46 51
I-net: www.ciap.tpu.ru
Academic exchange coordinators/
Координаторы по академическим обменам:
1. Anna S. Tseluyko
Целуйко Анна Сергеевна
E-mail: [email protected]
Научный руководитель
Name: _________________________________
Имя, фамилия
Phone:
_________________________________
Тел.
Fax:
_________________________________
Факс
E-mail: ________________________________
2. Olesya A. Zavadovskaya
Завадовская Олеся Александровна
E-mail: [email protected]
STUDENT APPLICATION FORM
ACADEMIC YEAR 2010 /2011
FIELD OF STUDY: .....................................................................................................................
This application should be completed in BLACK in order to be easily copied, faxed or e-mailed
STUDENT’S PERSONAL DATA
Информация о студенте
Family Name: .............................................................................
Фамилия
First Name: ................................................................................
Имя
photo
фото
Date of Birth: ..............................................................................
Дата рождения
Sex: .................................. Citizenship: ....................................................
Пол
Гражданство
Place of Birth: ....................................
Дата рождения
Current address:
Permanent address (if different):
Фактический адрес
Адрес по прописке
...............................................................................
..............................................................................
..............................................................................
..............................................................................
Current address is valid until: ............................
Фактический адрес действителен до
...............................................................................
...............................................................................
...............................................................................
...............................................................................
Tel.: .......................................................................
Fax: .......................................................................
E-mail: ..................................................................
Tel.: .....................................................................
Fax: .....................................................................
E-mail: ................................................................
Passport No............................................................ The city (in your country) you plan to get your
Номер паспорта
visa in:
Valid until: ....................................................... Город (в Вашей стране), где вы планируете
получить визу
Годен до
.........................................................................
Diploma/degree for which you are currently studying: .......................................................................
Диплом/степень, которую Вы получите по окончанию обучения
Date when you began these studies: ..................................................................................................
Дата начала обучения
Date when you expect to complete these studies: ...............................................................................
Дата окончания обучения
LANGUAGE PROFICIENCY
Языковая компетентность
Language of instruction at TPU (mark the fitting option with a “V”):
Язык обучения в ТПУ (отметьте нужное “V”):
Russian………..
English…………
Русский
Английский
My Russian language proficiency equals to:
Уровень владения русским языком
□ … years of studying in total
общее количество лет обучения
□ … zero level
…beginner
…intermediate level
…advanced level
«нулевой» уровень
базовый уровень
средний уровень
продвинутый уровень
REQUEST FOR STUDIES AT TPU:
Планируемая программа обучения в ТПУ
Period of study:
from ......................
Период обучения:
с
to ...........................
по
Field of study requested: ..................................................................................................................
Специализация
.............................................................................................................................................................
Type of program: project/ thesis/ laboratory/ seminars/ courses/ internship/ other:
Тип занятий:
проекты/науч.исследования/лабораторные/семинары/курсы/стажировка/другое
.............................................................................................................................................................
.............................................................................................................................................................
Do you want to study Russian at TPU?
Yes
No
Хотите ли Вы изучать русский язык в ТПУ?
Да
Нет
Do you want to pass the Test of Russian as Foreign Language at TPU?
Хотите ли Вы сдать государственный экзамен на сертификат по русскому языку?
Yes
No
Да
Нет
MOTIVATION: Why do you wish to study at Tomsk Polytechnic University?
Мотивация:
Почему Вы хотите обучаться в ТПУ?
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
Would you like to live in the University’s dormitory during your stay in Tomsk?
Вы хотели бы проживать в университетском общежитии во время визита в Томск?
Yes
No
да
нет
Note:
Your application should be accompanied by OFFICIALLY CERTIFIED ACADEMIC RECORDS AND
PASSPORT COPY
Внимание:
Не забудьте приложить к Вашему заявлению официально заверенную академическую справку и копию
паспорта.
ECTS - EUROPEAN CREDIT TRANSFER AND ACCUMULATION SYSTEM
LEARNING AGREEMENT
ACADEMIC YEAR 20..../20.... - FIELD OF STUDY: ...........................
Name of student: ..................................................................................................................................................................
Sending institution:.................................................................................................................................................
................................................................................................. Country: .......................................................................
DETAILS OF THE PROPOSED STUDY PROGRAMME ABROAD/LEARNING AGREEMENT
Receiving institution: ……………………………………………………………………………………………………..
................................................................................................ Country: ......................................................................
Course unit code (if
any) and page no. of
the information
package
Course unit title (as indicated in the information package)
Number of
ECTS credits
if necessary, continue the list on a separate sheet
Student’s signature
...........................................................................................
Date: ..................................................................................
SENDING INSTITUTION
We confirm that the proposed programme of study/learning agreement is approved.
Departmental coordinator’s signature
Institutional coordinator’s signature
.........................................................................................................
...........................................................................................................
Date: ................................................................................................
Date: .................................................................................................
RECEIVING INSTITUTION
We confirm that this proposed programme of study/learning agreement is approved.
Departmental coordinator’s signature
Institutional coordinator’s signature
.........................................................................................................
...........................................................................................................
Date: ................................................................................................
Date: .................................................................................................
Name of student: .............................................................................................................................................................
Sending institution:
....................................................................................................... Country: ............................................................
CHANGES TO ORIGINAL PROPOSED STUDY PROGRAMME/LEARNING AGREEMENT
(to be filled in ONLY if appropriate)
Course unit code (if any)
and page no. of the
information package
Course unit title (as indicated in the
information package)
Deleted
course
unit
Added
course
unit
Number of
ECTS credits
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if necessary, continue this list on a separate sheet
Student’s signature
.......................................................................................... Date: ..........................................................
SENDING INSTITUTION
We confirm that the above-listed changes to the initially agreed programme of study/learning agreement are approved.
Departmental coordinator’s signature
Institutional coordinator’s signature
.....................................................................................
..................................................................................................
Date: ....................................................................
Date: ...............................................................................
RECEIVING INSTITUTION
We confirm bye the above-listed changes to the initially agreed programme of study/learning agreement are approved.
Departmental coordinator’s signature
Institutional coordinator’s signature
.....................................................................................
...................................................................................................
Date: ....................................................................
Date: .................................................................................