Student Exchange Form.pdf

STUDENT EXCHANGE APPLICATION FORM
academic year /
1.- PERSONAL DATA
Family Name:
First name:
(Full) Address:
Telephone:
e-mail:
Identity card / Passport:
Sex:
Date of birth:
Place of birth:
2.- MOBILITY INFORMATION
Home institution:
Town:
Country:
Field of study:
Chemical Engineering
Electrical Engineering
Mechanical Engineering
Electronics and Automatic Control
Mining Engineering
IT Systems Engineering
Master’s degree in Natural Resources Engineering
Master's degree in Mining Engineering
Contact at home institution:
Telephone:
Fax:
e-mail:
Intended period of stay at the EPSEM
From:
To:
Academic Calendar:
1st semester: Mid September – End January
2nd semester: Mid February – End June
Duration of stay (in months):
3.- PROPOSED EDUCATIONAL PROGRAMME
Final Thesis
Subjects
Subjects Interest :
4.- LANGUAGE PROFICIENCY
Spanish language level (high, medium, low):
English language level (high, medium, low) :
Date: _
Signature of the academic advisor
at home institution
Signature of the applicant
Photo
Nº of semesters you have completed to date: