International Student Affairs
Attn: «Voornaam» «Achternaam»
International Student Affairs
Name home university
Name Exchange Coordinator
Email address
Telephone number
Requested period of exchange
 Fall semester
Sep – Jan ______
year
 Spring semester
Feb - Jun ______
year
 Full year
Sep - Jun ______
year
 Split year
Feb - Jan ______
year
Personal Details
Family name
Given name(s)
Preferred given name
Gender
Nationality
Place of birth
Country of birth
Date of birth
Address
Postal code
City
Country
Telephone number
Email address
2nd Email address
 male
Day:
 female
Month:
Year:
Educational background at home university
Field of study
Specialization
Years of study completed
Expected date of graduation
Bachelor:
Master:
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International Student Affairs
Attn: «Voornaam» «Achternaam»
International Student Affairs
Requested faculty/department at UvA
 College of Child and Educational Science
 College of Social Science
 Department of Psychology
 Faculty of Economics and Business
 Faculty of Humanities
 Law Faculty
 Graduate School of Social Science; only applicable for the Research Master Metropolitan Sciences
 Institute for Interdisciplinary Studies
 Other namely:
Study plan
See UvA course selection form
List of courses you would like to take at UvA
# of (local) credits
1.
2.
3.
4.
5.
6.
7.
8.
Please indicate if you are flexible in regards to course selection
 yes  no
Please note that this is a temporary study plan. Enrolment in courses is subject to availability and
faculty approval. Course registration will take place after acceptance at the UvA.
Other study or research plans (describe on a separate sheet of paper if necessary):
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International Student Affairs
Attn: «Voornaam» «Achternaam»
International Student Affairs
English Language Proficiency
See UvA fact sheet
You will be required to show of your English language proficiency if English is not your first language.
Please attach proof of you English proficiency
Test name:
Result:
If you have not yet taken a test, please indicate date of exam:
Courses in progress
Please list any courses that you are currently enrolled in but are not listed on your transcript
Course name
Semester
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2
3
4
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Is there anything you would like to comment on your personal circumstances that might be relevant for
your application (academic restrictions, study delay, medical or psychological background). Please
know that the answer to this question will be treated with the utmost confidentiality
Checklist
Have you include the following:
 Photo
 Certified copies of academic transcripts from all colleges / universities attended
 Certified copy of English language result (for non-native speakers only)
 Letter of motivation / statement of interest ( approx. 400-500 words)
 Curriculum vitae (resume)
 A copy of your passport (identity-page) or identity card
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International Student Affairs
Attn: «Voornaam» «Achternaam»
International Student Affairs
Applicant’s signature
Date
Please return this form and supporting documents to your home exchange
coordinator
Universiteit van Amsterdam
International Student Affairs
Attn. Mr. Guido de Wilde
Binnengasthuisstraat 9
1012 ZA Amsterdam
The Netherlands
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