LLP-ERASMUS STUDENT MOBILITY

STUDENT  APPLICATION  FORM
											(Photograph)

ACADEMIC YEAR 20.…/20.…

FIELD OF STUDY: .........................................................

This application should be completed in BLACK in order to be easily copied and/or telefaxed.

SENDING INSTITUTION, FACULTY
Name and full address: MEDICAL UNIVERSITY OF WARSAW, PL WARSZAW06
61, Żwirki i Wigury St., 02-091 Warsaw, POLAND, International Relations Office
Erasmus Institutional Coordinator - name, telephone and telefax numbers, e-mail: 
Prof. Anna Barańczyk-Kuźma, MD, PhD, lidia.przepiora@wum.edu.pl, 
tel. 48 22 572 02 19, fax 48 22 572 04 55
Erasmus Faculty Coordinator - name, telephone and telefax numbers, e-mail:
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STUDENT’S PERSONAL DATA
(to be completed by the student applying)

Family name: .......................................................
Date of birth: .......................................................
Sex: ...............Nationality:...................................
Place of Birth: .....................................................
Current address: ..................................................
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Current address is valid until: .............................
Tel.: .....................................................................
	First name (s): .................................................................

Permanent address (if different): ....................................
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Tel.: ..................................................................................	
LIST OF INSTITUTIONS WHICH WILL RECEIVE THIS APPLICATION FORM (in order of preference):

Institution
	Country	Period of study
from          to	Duration of stay (months)	N° of expected credits
(hours)	
1. ........................................
2. ........................................
3. ........................................	.....................
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Name of student: ...............................................................................................................................................
Sending institution, Faculty:............................................................................................. 
Country: ...............................................................

Briefly state the reasons why you wish to study abroad ?
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LANGUAGE COMPETENCE
Mother tongue: ................... Language of instruction at home institution (if different): ..................................	
Other languages	I am currently studying this language	I have sufficient knowledge to follow lectures	I would have sufficient knowledge to follow lectures if I had some extra preparation	
	yes	no	yes	no	yes	no	
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WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant)
Type of work experience

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..............................................	Firm/organisation

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.............................................	Dates

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.............................	Country

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PREVIOUS AND CURRENT STUDY
Diploma/degree for which you are currently studying: ....................................................................................
Number of higher education study years prior to departure abroad: ................................................................
Have you already been studying abroad ?                Yes             No 
If Yes, when ? at which institution ? .................................................................................................................

The attached Transcript of records includes full details of previous and current higher education study. Details not known at the time of application will be provided at a later stage.	

Do you wish to apply for an ERASMUS mobility grant to assist towards the additional costs of your study period abroad?                                Yes           No 	

RECEIVING INSTITUTION, Department:
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We hereby acknowledge receipt of the application, the proposed learning agreement and the candidate’s Transcript of records.	
The above-mentioned student is                       

Tutor’s signature
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Date: ....................................................................	provisionally accepted at our institution
not accepted at our institution
Dean’s signature
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Date :.............................................................................