/ Student
Application
Form
Summer School Modular
2015 / Photo
This application should be completed in BLACK PRINT in order to be easily copied and/or faxed. Please note that we will only proceed with complete applications.
Field of Study:
Bioengineering
Systems Engineering
Materials Engineering / Computer Science Mechanical Engineering
Chemical Engineering Digital Media Engineering
Electrical Engineering Other …………………………...
Receiving Institution
Name:Université de Technologie de Compiègne - Directorate International Relations
Address: Rue Roger Couttolenc, BP60319, 60203 Compiègne Cedex, France
Incomings Coordinator:
Name: / Gaëlle DACQMINE
Phone: / 0033 (0)3 44 23 49 63
Fax: / 0033 (0)3 44 23 73 88
E-mail: /
Modules
Module 1 / Laboratory projects in Bioeconomy / Intelligent Mobility / Health Technology (Mid-May – End of July 2015)
Module 2 / Intensive French language training (July 6-31, August 3-30, 2015)
Module 3 / International School “Culinary Science for Tastier, Healthier Food” (July 20-31, 2015)
Student’s personal data
Family name: / First name:
Date of birth: / Place of birth:
Nationality: / Sex:
Current correspondence address: / Permanent home address:(if different)
Street: / Street:
Post Code: / Post Code:
City: / City:
Country: / Country:
Phone: / Phone:
E-Mail: / Current address is valid until:
Language skills
Mother tongue:
Language of instruction at the home institution:
Other languages: / Language proficiency level (as confirmed by sending institution) / I am currently studying this language: / I have sufficient knowledge to follow lectures: / I would have sufficient knowledge to follow lectures if I had some extra preparation:
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Yes No / Yes No / Yes No
Insurance
Are you covered by this insurance during your stay in France?
Yes No
Name and address of your health insurance company:
______
Application Procedure
  1. Complete this form: UTC Summer School Modular 2015.Make sure that your photo is attached/pasted into the application.
  2. Make and attach pdfs of:
  3. Resume/CV
  4. Motivation letter
  5. Copy of your Passport
  6. Copy of your Health Insurance Card (front and back)
  7. Please check updated information on
Application Deadline: Wednesday, April 30th, 2015
Student’s signature: Date:

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