Diplôme d’Ingénieur Civil des Mines
ERASMUS PROGRAM AND
BILATERAL EXCHANGE AGREEMENTS

APPLICATION FORM 2015-2016

Family name:
First name:
Date of Birth:
Sex F or M Nationality
Place of Birth / Permanent address (complete with post code):
Address during summer holidays (if different):
Phone:
Email:
HOME INSTITUTION:
Name and full address of home institution:
Name & function of professor or advisor responsible for your exchange program :
E-mail:
Phone:

APPLICATION FOR:

Full academic year 20 / 20 : YES or NO
Semester 20 , from to : YES or NO
Field of study (major at home institution) :

LANGUAGE SKILLS:

Mother tongue:
Language of instruction at home institution (if different):
Other
Languages / I am currently studying
this language / Years of study / Level
YES or NO
YES or NO

WORK EXPERIENCE (internship, industrial & lab placement, job):

Type of work experience / Firm/organization / Dates / Country

PREVIOUS AND CURRENT STUDY:

Diploma/degree for which you are currently studying:
Number of years of higher education prior to departure abroad:
Have you already been studying abroad? YES or NO If Yes, when?
At which institution?

PROVISIONAL STUDY PROGRAM (SUBJECT TO CONFIRMATION)

Diplôme d’Ingénieur Civil des Mines

ACADEMIC YEAR 20 - 20
Family name & surname:
Sending institution:
Country:
Course title / Semester / ECTS credits
The application package should include the following documents:
-  the completed and signed application form with your photograph
-  original transcripts of all your academic years of higher education
-  official certificates of French and English skills
-  your provisional study plan at EMSE
-  your resume (in French or English)
-  copy of your passport/ID card
-  copies of all your higher education diplomas
It should be mailed to:
Mines Saint-Etienne
Direction des Formations Etudiantes-Mobilité académique
158, cours Fauriel
CS 62362
42023 SAINT-ETIENNE Cedex 2
FRANCE
Or e-mailed to
I hereby certify that all statements and supporting documentation are correct and complete. I understand that any misrepresentation may result in the cancellation of my admission or registration status and I may be required to submit documentary evidence to substantiate my declarations at a later date.
Applying student’s signature
Date: