STUDENT APPLICATION FORM - Technische Universiteit Eindhoven
STUDENT APPLICATION FORM - Technische Universiteit Eindhoven
STUDENT APPLICATION FORM - Technische Universiteit Eindhoven
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<strong>STUDENT</strong> <strong>APPLICATION</strong> <strong>FORM</strong><br />
Please enclose copy of passport, one passport photo (3 x 4 cm) and transcript of records<br />
ACADEMIC YEAR 20.. /20..<br />
PREFERRED FIELD OF STUDY AT TU/e: .........................................................<br />
This application should be completed in BLACK in order to be easily copied, faxed or e-mailed<br />
SENDING INSTITUTION<br />
Name and full address: ......................................................................................................................................<br />
............................................................................................................................................................................<br />
Department coordinator - name, telephone, fax and e-mail ..................................................<br />
............................................................................................................................................................................<br />
............................................................................................................................................................................<br />
Institutional coordinator - name, telephone, fax and e-mail ..................................................<br />
............................................................................................................................................................................<br />
............................................................................................................................................................................<br />
<strong>STUDENT</strong>’S PERSONAL DATA<br />
(to be completed by the student applying, data should be conform information in passport)<br />
Family name (for married woman maiden name):<br />
.......................................................<br />
Date of birth: .....…/.........../.....................<br />
Sex: Male / Female<br />
Nationality:...................................<br />
Place and country of birth:<br />
.....................................................<br />
Current address: ..................................................<br />
..............................................................................<br />
..............................................................................<br />
..............................................................................<br />
Current address is valid until: .............................<br />
Tel.: .....................................................................<br />
Fax: .....................................................................<br />
E-mail: ................................................................<br />
RECEIVING INSTITUTION<br />
Institution<br />
TU <strong>Eindhoven</strong><br />
Department of<br />
Mathematics & Computer<br />
Science<br />
Country Period of study<br />
The<br />
Netherlands<br />
First name(s): .................................................................<br />
Marital status: unmarried / married<br />
Permanent address (if different): ....................................<br />
..........................................................................................<br />
..........................................................................................<br />
..........................................................................................<br />
..........................................................................................<br />
Tel.: .................................................................................<br />
Fax: .................................................................................<br />
E-mail: ............................................................................<br />
from to<br />
............<br />
...........<br />
Duration of stay<br />
(months)<br />
...................<br />
N° of expected<br />
ECTS credits<br />
.............................
Preferred type of study during stay at TU/e:<br />
Courses<br />
Research project, please specify in which research area: ………………………………………………<br />
Final project/thesis project, please specify in which research area: ……………………………………<br />
Internship, please specify in which research area: ……………………………………………………..<br />
Briefly state the reasons why you wish to study abroad?<br />
...........................................................................................................................................................................<br />
............................................................................................................................................................................<br />
............................................................................................................................................................................<br />
LANGUAGE COMPETENCE<br />
Mother tongue: ................... Language of instruction at home institution (if different): ..................................<br />
Other languages I have sufficient<br />
knowledge to follow<br />
lectures<br />
English<br />
(Dutch)<br />
..........................<br />
I am currently studying this<br />
language<br />
I would have sufficient knowledge to<br />
follow lectures if I had some extra<br />
preparation<br />
yes No yes no yes no<br />
<br />
<br />
<br />
<br />
<br />
<br />
WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant)<br />
Type of work experience<br />
..............................................<br />
..............................................<br />
PREVIOUS AND CURRENT STUDY<br />
<br />
<br />
<br />
Firm/organisation<br />
.............................................<br />
.............................................<br />
<br />
<br />
<br />
Dates<br />
<br />
<br />
<br />
.............................<br />
.............................<br />
<br />
<br />
<br />
Country<br />
.......................................<br />
.......................................<br />
Diploma/degree for which you are currently studying: ....................................................................................<br />
Current field of study:…………………………………………………<br />
Number of higher education study years prior to departure abroad: ................................................................<br />
Have you already been studying abroad? Yes No <br />
If Yes, when? At which institution? .................................................................................................................<br />
The attached Transcript of records includes full details of previous and current higher education<br />
study. Details not known at the time of application will be provided at a later stage.<br />
NATURE OF VISIT AND GRANT<br />
What is the nature of your visit? Erasmus/Socrates agreement between TU/e and your institution<br />
Other bilateral agreement between TU/e and your institution<br />
Leonardo<br />
Iaeste<br />
Free mover<br />
Other, please specify ………………………………………….
Do you wish to apply for a mobility grant to assist<br />
towards the additional costs of your study period<br />
abroad?<br />
If so, please indicate which mobility grant. 1<br />
SENDING INSTITUTION<br />
Coordinator’s Name<br />
..............................................................................<br />
Yes No <br />
Erasmus/Socrates<br />
Leonardo<br />
Other, namely<br />
<br />
<br />
………………………<br />
Date: ....................................................................<br />
Coordinator’s signature + stamp institution<br />
RECEIVING INSTITUTION (to be completed by TU/e Department of Mathematics & Computer<br />
Science)<br />
We hereby acknowledge receipt of the application, the candidate’s transcript of records and the learning<br />
agreement.<br />
The above-mentioned student is <br />
<br />
Departmental coordinator’s signature<br />
..............................................................................<br />
Date: ....................................................................<br />
Accepted at our institution<br />
Not accepted at our institution<br />
Supervisor TU/e: _________________________________________________________<br />
Bachelor’s/Master’s program: _______________________________________________<br />
Period of study at TU/e: _______________________________________________<br />
Please enclose:<br />
- copy of passport<br />
- one passport photo (3 x 4 cm.)<br />
- transcript of records of previous and current higher education<br />
- learning agreement with proposed study program (if already known)<br />
Please return this form to:<br />
<strong>Technische</strong> <strong>Universiteit</strong> <strong>Eindhoven</strong><br />
Department of Mathematics & Computer Science<br />
Mr. Wil Linders<br />
Room: HG. 6.31<br />
PO Box 513<br />
5600 MB <strong>Eindhoven</strong><br />
The Netherlands<br />
1 Please apply for a mobility grant at your home institution (if applicable).
Annex to application form (compulsory)<br />
Family name (for married woman maiden name): ___________________________________<br />
First name(s): ____________________________________________________________<br />
Date of birth: ____/____/________ Place of birth: ______________________________<br />
Country of birth: ____________________ Nationality: _________________________<br />
Email: ___________________________________________<br />
Sex: male / female Marital status: unmarried / married<br />
-----------------------------------------------------------------------------------------------------------------------------------<br />
Wishes to apply for:<br />
ACCOMMODATION (please answer the following questions)<br />
Accommodation period: from ____/____/________ until: ____/____/________<br />
Accompanied by family?<br />
Maximum rent per month (in Euro): €_____________<br />
Kind of accommodation:<br />
Special remarks (e.g. allergic to pets):<br />
No<br />
Yes Number of persons: _______________<br />
State name and ages: ____________________________________<br />
_____________________________________<br />
_____________________________________<br />
Period of stay family: from ____/____/________ until: ____/____/________<br />
Fellowtel / student’s house / landlady / other<br />
smoking / non-smoking<br />
VISA 2 (please answer the following questions):<br />
Do you have a Dutch residence permit: yes / no<br />
----------------------------------------------------------------------------------------------------------------------------------------<br />
Insurance (please answer the following questions)<br />
Do you have health insurance? 3<br />
Do you have liability insurance?<br />
If not, please contact the International Relations Office on arrival.<br />
Undersigned by:<br />
Student Coordinator Department of Mathematics and Computer Science<br />
2 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.<br />
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<br />
of the European Union, Iceland, Norway, Liechtenstein, Switzerland, Monaco, Australia, New Zealand, Canada, the United States of<br />
America and Japan.<br />
3 The Netherlands has signed treaties regarding health insurance with the following countries: all of the EU member states, Norway,<br />
Iceland, Liechtenstein, Turkey, Morocco, most of the countries of former Yugoslavia, Tunisia, Cape Verde Islands and Australia. If you are<br />
insured under the national health insurance scheme of one of these countries, your insurance company can provide you with an<br />
international declaration form called E-111 or E-128. Make sure to bring this form with you to the Netherlands.
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