Surname
(as indicated in Passport or Identity card) / First name:
(as indicated in Passport or Identity card)
Date of birth: (dd/mm/yyyy) / Place and Country of birth:
Nationality: / Gender:(M/F)
Home Address:
(please indicate your full address: Address, Town, Post/Zip Code)
Document: (passport or ID card) / ID card or passport number
Date of Expiry
Telephone Number:
Mobile Number: / E-mail Address:
Do you require Disability or Learning Support? / Yes ☐ No ☐
HOME UNIVERSITY
Title of your current degree programme:
Number of years of higher education (University) study completed to date (In which year of your current course programme are you enrolled in?)
HOST INSTITUTION
Host University Name:
Degree programmeyou would like to attend
Mobility period (n° of months):
Please specify: / ☐Autumn term (from September 2017……)
☐Spring term (from January 2018 …..)
☐…………………………….
PRIOR EXPERIENCE UNDER Erasmus + Programme AND/OR Erasmus Mundus Programme
Do you have any prior experience under Erasmus+ programme (mobility for study and/or mobility for traineeship)? / Yes ☐ No ☐
If yes, please specify: / Type of mobility:
Level of Studies:
☐1st cycle/1st level/undergraduate;
☐2nd cycle/2nd level/Master;
☐3rd cycle/3rd level/PhD):
Dates:
Do you have any prior experience under Erasmus Mundus programme? / Yes ☐ No ☐
If yes, please specify: / Type of mobility:
☐1st cycle/1st level/undergraduate;
☐2nd cycle/2nd level/Master;
☐3rd cycle/3rd level/PhD)
Dates:
The undersigned wishes to apply for the Erasmus+ - International Credit Mobility grant to ……………………………….. University, according to the Call for Applications published on...... ……., 2017.
Compulsory attachments:
For BA and MA candidates:
- Copy of a valid ID card or passport;
- Copy of a residence document (residency permit or carte de séjour) if not a Russian citizen;
- Copy of certificate of enrolment at HSE- Nizhny Novgorod;
- Copy of the transcripts of records, indicating university grades/marks for accomplished first-cycle degree;
- Filled in Self-assessment grid of Common European Framework of Reference for Languages (Europass) approved by a language teacher
- Proposed Learning agreement;
- Curriculum Vitae (max 2 pages) in English including extra-curricular activities (courses, seminars, conferences, published research, etc.) and professional experience related to the fields of the mobility. Please use the European template on
- Motivation letter (max 2 pages) explaining the background of the candidate and the reasons for applying to the programme;
SIGNATURE OF APPLICANT
I confirm that the information provided on this application form is correct.
Signature: / Place and Date: