LLP (Erasmus) STUDENT APPLICATION FORM: STUDY ABROAD ...

LLP (Erasmus) STUDENT APPLICATION FORM:STUDY ABROAD (SMS)The blanket has to be filled in electronically and mailed to ldr@viauc.dk and also send by post with signature andstamp to VIA University College, Egebjergvej 1, 8751 Gedved, DK, att.: Lone Drescher.PERIOD OF STUDY ABROADPeriod of study abroad:Please indicate which semestersubstitutes your study abroad:Spring semester 200__ / Autumn semester 200__Semester number ____ of ____ semestersSENDING INSTITUTIONFaculty / School:Programme of study:Head of Programme / Department:International contact person: NamePhoneE-mailFaxSending institution:STUDENT’S PERSONAL DATAFirst name(s):Last name(s):Sex: Male __ / Female __ Civ. Reg. No.:Phone:In home country:While abroad:Student No.:Nationality:Permanentaddress inhome country:E-Mail at homeinstitution:Place of birth:Current addressabroad– validuntil:Private E-mail:Next of KinInformation:Whom tocontact ifnecessary.Name:Address:Phone:E-mail:PREFERRED INSTITUTIONS (in order of preference)Institution Country Period of Study1.FromToDuration ofstay(months)No. ofexpectedECTScredits2.

Briefly state the reasons why you wish to study abroad:LANGUAGE COMPETENCEMother tongue: __________________Language of instruction at home institution (if different): _________________Language test results: Language test at: _________________ Score result: _______________OtherlanguagesEnglishHostCountryI am currently studyingthis languageI have sufficientknowledge to followlecturesI will have sufficientknowledge to followlectures if I get someextra preparationYes No Yes No Yes NoPREVIOUS AND CURRENT STUDYNumber of higher education study years prior to departure abroad:Have you already been studying abroad? Yes: ___ No: ___If yes, when?At which institution?Have you received an ERASMUS grant previously? Yes:__ No:__If yes which grant, when and for which activity?The attached “Learning Agreement” includes full details of required courses and projects toattend during my intended study period at the Host University.Name of student:Approved by Sending Institution:Date:Date:_________________________________Signature_________________________________Signature (Int. Contact Person)RECEIVING INSTITUTION:We:__________________________________________________________________________hereby acknowledge receipt of the application and the student’s proposed Learning Agreement.The above-mentioned student is:accepted at our institution ___not accepted at our institution ___International contact personHead of ProgrammeName:E-mail:Phone: +Name:Date:________________________________Signature2