student application form exchange students - Technische ...

STUDENT APPLICATION FORM EXCHANGE STUDENTS
This application should be completed in BLACK in order to be easily copied, faxed or e-mailed
STUDENT’S PERSONAL DATA
(to be completed by the student applying, data should be conform information in passport)
Family name (for married woman maiden name):
.......................................................
Date of birth: .....…/.........../.....................
Sex: Male / Female
Nationality:...................................
Place and country of birth:
.....................................................
Current address: ..................................................
..............................................................................
..............................................................................
..............................................................................
Tel.: .....................................................................
Fax: .....................................................................
E-mail: ................................................................
First name(s): .................................................................
Marital status: unmarried / married
Permanent address (if different): ....................................
..........................................................................................
..........................................................................................
..........................................................................................
..........................................................................................
Tel.: .................................................................................
Fax: .................................................................................
E-mail: ............................................................................
SENDING INSTITUTION
Name and full address: ......................................................................................................................................
............................................................................................................................................................................
Department coordinator - name, telephone, fax and e-mail ..................................................
............................................................................................................................................................................
............................................................................................................................................................................
Institutional coordinator - name, telephone, fax and e-mail ..................................................
............................................................................................................................................................................
............................................................................................................................................................................
PREVIOUS AND CURRENT STUDY
Diploma/degree for which you are currently studying:……………………………………………………….
Current field of study:…………………………………………………………………………………………
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.

RECEIVING INSTITUTION
PREFERRED FIELD OF STUDY AT TUE:…………………………………………………………
ACADEMIC YEAR:………………………………………………………………………………….
Institution
TU Eindhoven
Department of Mechanical
Engineering
Country Period of study
The
Netherlands
Semster x to Semester y
............
...........
N° of expected
ECTS credits
.............................
Preferred type of study during stay at TU/e:
Courses
Research project, please specify in which research area: ………………………………………………
Final project/thesis project, please specify in which research area: ……………………………………
Internship, please specify in which research area: ……………………………………………………..
Briefly state the reasons why you wish to study abroad?
...........................................................................................................................................................................
............................................................................................................................................................................
............................................................................................................................................................................
NATURE OF VISIT AND GRANT
What is the nature of your visit? Erasmus study (courses, traineeship, at the university, on the basis
of a bilateral agreement)
Erasmus student placements (in a company)
Erasmus Mundus External Cooperation Window
Within the scheme of another (non-Erasmus) bilateral agreement
between TU/e and your institution
Free mover
Other, please specify ………………………………………….
LANGUAGE COMPETENCE
Mother tongue: ................... Language of instruction at home institution (if different): ..................................
English
(Dutch)
I have sufficient knowledge to follow lectures
yes No
Please give a proof of your sufficient knowledge of the English language in one of the following
ways:
- An original Academic IELTS score of at least 6.0 on average
- TOEFL scores of at least 80 (internet-based), 213 (computer-based) or 550 (paper-based)
- Statement of your home institution (please use annex II)

WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant)
Type of work experience
..............................................
..............................................
Firm/organisation
.............................................
.............................................
Dates
.............................
.............................
Please enclose:
- copy of passport
- one passport photo (3 x 4 cm.)
- transcript of records of previous and current higher education
- learning agreement with proposed study program (if already known)
- proof of sufficient mastery of the English language
Please return this form to:
Technische Universiteit Eindhoven
Department of Mechanical Engineering
Ms. Liesbeth van Ballegooij
Room: WL 1.16
PO Box 513
5600 MB Eindhoven
The Netherlands
Country
.......................................
.......................................

DECLARATION AND SIGNATURES
SENDING INSTITUTION
Coordinator’s Name:
..............................................................................
Coordinator’s signature
Date:
…………………………………………………………..
Stamp institution
RECEIVING INSTITUTION (to be completed by TU/e Department of Mechanical Engineering)
We hereby acknowledge receipt of the application, the candidate’s transcript of records and the learning
agreement.
The above-mentioned student is
Departmental coordinator’s signature
..............................................................................
Date: ....................................................................
Accepted at our institution
Not accepted at our institution
Supervisor TU/e: _________________________________________________________
Bachelor’s/Master’s program: _______________________________________________
Period of study at TU/e: _______________________________________________

Annex I Application form for Services (compulsory)
Family name (for married woman maiden name): ___________________________________
First name(s): ____________________________________________________________
Date of birth: ____/____/________ Place of birth: ______________________________
Email: ___________________________________________
Country of birth: ____________________ Nationality: _________________________
Sex: male / female Marital status: unmarried / married
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Wishes to apply for:
ACCOMMODATION (please answer the following questions)
Accommodation period: Semester 1 Semester 2
(Semester 1: 10 August 2009 to 26 January 2010)
(Semester 2: 29 January 2010 to 23 July 2010)
Maximum rent per month (in Euro): € 350, 400, 450, 500, >500
(circle your budget)
Special remarks:
VISA 1 (please answer the following questions):
Do you have a Dutch residence permit: yes / no
(If you choose “no” and you need a VISA the TU/e will apply for it)
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Insurance (please answer the following questions)
Do you have health insurance? 2 Yes No
Do you have liability insurance? Yes No
If you do not have insurance you need to contact the International Relations Office on arrival. We can arrange
insurance for you with AON (www.students-insurance.eu)
Undersigned by:
Student Coordinator Department of Mechanical Engineering
1 If you come to the Netherlands as an exchange student for more than 3 months you might need an MVV (visa) to enter the Netherlands.
Students with the nationality of one of the following countries do not need to apply for a visa to enter the Netherlands: One of the countries
of the European Union, Iceland, Norway, Liechtenstein, Switzerland, Monaco, Australia, New Zealand, Canada, the United States of
America and Japan.
2 The Netherlands has signed treaties regarding health insurance with the following countries: all of the EU member states, Norway, Iceland,
Liechtenstein, Turkey, Morocco, most of the countries of former Yugoslavia, Tunisia, Cape Verde Islands and Australia. If you are insured
under the national health insurance scheme of one of these countries, your insurance company can provide you with an international
declaration form called E-111 or E-128. Make sure to bring this form with you to the Netherlands.

Annex II statement of home institution regarding mastery of the English language
Family name (for married woman maiden name): ___________________________________
First name(s): ____________________________________________________________
Date of birth: ____/____/________ Place of birth: ______________________________
Email: ___________________________________________
Country of birth: ____________________ Nationality: _________________________
Sex: male / female Marital status: unmarried / married
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[Coordinator’s Name] confirms that the mentioned student has a sufficient knowledge of the English language
comparable with:
A) an original Academic IELTS score of at least 6.0 on average
B) TOEFL scores of at least 80 (Internet-based), 213 (computer-based) or 550 (paper-based).
Name coordinator: ..............................................................................
Date: ....................................................................
Signature coordinator stamp institution