Application form –2016

Only fully completed and signed applications can be accepted!

1. APPLICANT’S PERSONAL DATA

Surname/Family name
(as indicated in your passport)
Forenames/Given names
(as indicated in your passport)
Date of birth (DD.MM.YY)
Place of birth
Gender / Female
Male
Identity card no. :
Expiry date:
Passport no. :
Expiry date:
Nationality
Native Language(s)
Family status

Current address

Street and number
Postcode
City
Country of residence

Permanent address(This address will be used to send all official documents in case of selection. You must insert the complete information and the most adequate address. Any problem in sending documents resulting from erroneous or insufficient information provided in this section and consequent need to resend the documents will result on the payment, by the candidate, of the expenses associated to this.)

Street and number
Postcode
City
Country

Contact details

Telephone (with country prefix):
Primary email:
Alternative email:

Additional information (By signing this application you declare you have not resided nor carried out your main activity - studies, work, etc., for more than a total of 12 months over the past five years in one of the European countries, not applicable for Target Group 3.)

How did you get to know the project?
Have you applied at the same time to other financial support (Project funded by the European Union or other) / Yes No
If yes, please specify which financial support.
Are you in a particularly vulnerable socio-economic situation? / Yes No
If yes, please upload a formal document (dated, signed and stamped by the issuing entity) that specifically proves your vulnerable situation.
Do you have any physical disability? / Yes No
If yes, please upload a formal document (dated, signed and stamped by the issuing entity) that specifically proves your vulnerable situation.

Your mobility:

Please mark:

Applicant from Target Group 1(Asian / EU/ Third country Partner university)

Applicant from Target Group 2 (Associate institutions)*

Applicant from Target Group 3 (Persons in vulnerable situations = disabled or economically disadvantaged people or indigenous population)

*More information at the website section Application

Application for (please choose only one option):

Undergraduates5 monthsor10 months

Masters 5 monthsor10 months

Doctorates 5 months or 10 months

Post Doctorates6 months

AcademicStaff1 month

2. HOME INSTITUTION

Full name of your current Home Institution (university, company, research centre, etc):
City
Country
Are you student:
Yes
Field of study
Name of the study program
Faculty/School
Department
Planned date of graduation
Name of the responsible person
Position of the responsible person
Email of the responsible person
No
Field of work
Description of your position

3. HOST INSTITUTION

Please choose max. 2 host universities from the list of Partner universities.

1st priority
Name of the institution:
Country
Field of study:
Duration of stay in months:
Start of the mobility (MM/YY):
End of the mobility (MM/YY):
Is your proposal part of any common project of the two institutions? / Yes No
If yes, please indicate the references.
Have you established any previous contacts with the Institution concerning your mobility? / Yes No
If yes, please quote the name of the contacted person.
Why have you chosen this type of mobility? (Max. 1000 characters)
Why have you chosen this specific institution? (Max. 1000 characters)
2nd priority
Name of the institution:
Country
Field of study:
Duration of stay in months:
Start of the mobility (MM/YY):
End of the mobility (MM/YY):
Is your proposal part of any common project of the two institutions? / Yes No
If yes, please indicate the references.
Have you established any previous contacts with the Institution concerning your mobility? / Yes No
If yes, please quote the name of the contacted person.
Why have you chosen this type of mobility? (Max. 1000 characters)
Why have you chosen this specific institution? (Max. 1000 characters)

4. PREVIOUS EDUCATION

Secondary School EducatioN

Name of the institution:
City
Country
Exact Date of the Final Examination (e.g. 12.06.2013)
Original name of examination
Please include a copy of your school leaving exam!

UNIVERSITY EDUCATIN(including study abroad):

Full name of the institution delivering your previous degree(s) – all the last degrees completed:

Name of the institution:
City
Country
Study programme
Period of study (give months and years)
Degree obtained
Result/Final grade
ADD THESE LINES ACCODING TO THE NUMBER OF DEGREES OBTAINED:
Name of the institution:
City
Country
Study programme
Period of study (give months and years)
Degree obtained
Result/Final grade

5. FOREIGN LANGUAGE COMPETENCE

Languages / In this language I can participate actively in scientific discussions without difficulties / 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

Language certificates (full name, date, score)______

______

Please provide a copy of an English certificate required by the university of your choice**!

Language tests, which will be taken before the scholarship______

Date of test______

** Visit the website check the English requirements for the university of your choice.

6. WORK EXPERIENCE RELATED TO CURRENT STUDY

Type of work experience / / Name of the Institution / Period / Country

7. Recommendation letter of Senior Academics

Title, Name of the recommending professor / Institution / Subject area of the professors

I certify that the information in this application is accurate; failure in filling true data can result in my exclusion from the project activities. I certify that I will tell personal changes and additions immediately to the project coordinator Czech University of Life Sciences Prague. I agree that this application and accompanying documents can be forwarded to partner Institutions, who are cooperating in this programme.

______

Place and dateSignature of the applicant

CHECKLIST FOR ENCLOSURES TO BE ADDED:

Please provide English translations of all the documents!

  1. CV
  2. Motivation letter describing your motivation(1 page)
  3. Academic transcript (an official list of courses you have attended so far, including Grade Point Average)
  4. Copy of your secondary school / high school leaving certificate or university entrance exam results(only for Bachelor students)
  5. Copy of your bachelor’s degree or an equivalent amount of ECTS credit points (180) if you want to register for a Master programme
  6. Copy of your Masters/diploma degree if you want to register for a PhD programme
  7. Copy of an official English language certificate + other language certificates (if any). Department of languages of the university can provide you relevant document.
  8. Copy of yourpassport (page with your picture)or personal ID card, if you do not have a passport

(Candidates finally selected for mobility will be required to obtain an international passport before being able to travel to Europe!)

  1. One passport-sized photograph
  2. Proof of registration (enrolment) at the university for exchange students for short term mobilities
  3. For BSc, MSc and PhD students: onerecommendation letter (from academic staff, employers or professional organization)
  4. For PhD, Post-Doc and Academic Staff: maximum 3-page research proposal including references (see the guidelines)
  5. If applicable: proof of belonging to target group 3 (e.g. medical certificate or confirmation of refugee status etc)

Other documents

After acceptance of your application, you may be requested to have ALL TRANSLATED DOCUMENTS OFFICIALLY AUTHORISED (AND ALL DOCUMENTS CERTIFIED by embassies/ministries as requested by your host university) and to submit additional documents (e.g. medical certificates).

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