STUDENT MOBILITY ABROAD Application form 2013 - Beaux-arts ...

STUDENT MOBILITY ABROAD
Application form 2013 – 2014
MOBILITY WITHIN THE FRAMEWORK OF:
tick the relevant choice
☐ A study period in a partner school within the framework of the ERASMUS programme
A personal project in France or abroad, or a study period in a school with which the ESBANM has no
agreement:
☐ OFAJ (Office Franco Allemand pour la Jeunesse)
☐ Specific project
☐ CREPUQ (Québec/Canada)
☐ Concordia University – Montréal – Québec/Canada
☐ Tokyo University of the Arts – Gedaï - Japon
☐ Korean National University of Arts – Séoul – Corée du Sud
☐ Central Academy of Fine Arts Beijing/Pékin - Chine
IDENTIFICATION SHEET
Surname: First name:
Date of birth: / / Place of birth:
Nationality: Gender: ☐M ☐F
Private address:
City: ZIP code:
Mobile phone: Landline phone:
Esbanm email address: Private email:
Name of the host institution, town and country
Choice n°1
Choice n°2
DESTINATIONS REQUESTED

Department in the host institution
Choice n°1
Choice n°2
« Situation » corresponding at ESBANM
Choice n°1
Choice n°2
COURSES CHOICE
MOBILITY PERIOD ABROAD
tick the relevant box
☐ Semester or trimester 1 ☐ Semester or trimester 2
☐ Trimester 3 ☐ Semesters or trimesters 1 et 2
☐ Trimesters 1, 2 et 3 ☐ Other dates
FOREIGN LANGUAGES
How would you assess your level in Foreign languages?
languages Beginner's level Intermediate level Advanced level
English ☐ ☐ ☐
Deutsch ☐ ☐ ☐
Spanish ☐ ☐ ☐
Italian ☐ ☐ ☐
Others ☐ ☐ ☐
Have you passed an officially recognised foreign language test?
☐ YES name of the test: ☐ NO
Would you like to follow foreign language classes during your stay at host institution?
☐ YES ☐ NO
If you study abroad within the framework of the Erasmus programme, would you like to follow
Intensive Erasmus Language Courses (IELC) – These courses take place before your study period abroad.
They aren’t proposed in the countries below : Espagne, Allemagne, Autriche et Grande – Bretagne -
☐ YES ☐ NO

HEALTH
If you think it necessary, please tell us about any physical disability or about any special needs that you
may have in relation to any medical problems:
PERSON TO CONTACT IN CASE OF EMERGENCY
Surname: First name:
Street address: City:
State: ZIP code:
Mobile phone: Landline phone:
E-mail address:
You must forward, by e-mail, and in one PDF file, this application form and the other documents detailed
below to Hubert Bernier (Pôle Mobilité – 1er étage – Bât C) – hubert.bernier@nantesmetropole.fr, not later
than one week before the date of the CPSVE:
• The statement letter
• The digital portfolio,
• The recommendation letter from a teacher of the ESBANM,
• The curriculum vitae,
DEADLINE TO APPLY TO MOBILITY ABROAD
CPSVE: February 12 2013 > deadline: February 5 2013
CPSVE: March 19 2013 > deadline: March 12 2013
CPSVE: April 16 2013 > deadline: April 9 2013
CPSVE: May 28 2013 > deadline: May 21 2013
CPSVE: June 25 2013 > deadline: June 18 2013

I hereby declare that the information given
above is true and that I agree to abide by the
rules of the host institution
Student's surname and first name
SIGNATURES
Date Signature
Validation du choix de l’établissement, en adéquation avec le projet artistique de l’étudiant
Cette validation concerne uniquement les candidatures Erasmus
Patricia SOLINI
enseignante et
coordinatrice ERASMUS
Aide à l’élaboration du dossier de mobilité
Cette validation concerne les candidatures hors programme Erasmus
DECISION
Rozenn LE-MERRER
directrice adjointe
des études
Date Signature
Date Signature
Pedagogic and Scientific Committee of the Life Student of the ESBANM
Avis du CPSVE (accepted, refused or postponed):
Pierre-Jean Galdin
Directeur / Head
Date Signature