Application form
Student mobility for Traineeship
ERASMUS+ Programme 2015/2016
Student’s home Faculty at the UL
......
Name of study programme at the UL, from which the Student applies: ......
Year of studies at the time of application ......
Student’s ID number ......
Study programme at the UL (please tick the appropriate type and level of study programme):
□ Full-time, day studies
□ Extramural, evening or weekend studies
□ Bachelor’s degree
□ Uniform (5-year-long) Master’s degree
□ Master’s degree
□ Doctoral degree
Other kind of study programme at the UL (if applicable)
......
Student’s personal data (please fill in the application form in CAPITAL letters:)
Surname:...... Name/s:......ID number or passport number ......
Date of birth:...... Place of birth:......
Current address: ......
Permanent address: ......
......
Current address is valid until ...... E-mail:......
Home phone number:...... Mobile phone number: ......
Application to traineeship abroad:
The Receiving institution......
...... / Country, city
......
...... / The traineeship period
(DD-MM-YYYY)
from: ...... until: ...... ……..
Number of months: ......
DOTYCHCZASOWY PRZEBIEG STUDIÓW (informacja dot. kierunku, z którego Student/ka ubiega się o wyjazd)
Średnia ocen, semestr zimowy 14/15:Grade average from the 2014/15 winter semester: / Średnia ocen z całego cyklu studiów:
Grade average from the whole study cycle:
The grade average is confirmed and entered by the authorized Dean’s Office staff .
Średnią ocen wpisuje i potwierdza upoważniony pracownik Dziekanatu.
Statement of international mobility pursued to date
I declare that:
1) I previously pursued an LLP Erasmus/ Erasmus+/Campus Europae/Scholarship and Training Fund mobility for studies:
with / without scholarship grant in the …………………………………….. academic year;
in the period (according to Confirmation of Stay) between ……….………and………………… ;
in the host institution named …………………………………………………………………….
country: ………………………………………………………………during:
a) first-cycle studies at the UL / other institution …………………………………
b) second-cycle studies at the UL / other institution …………………………………………
c) third-cycle studies at the UL / other institution ……………………………………………
d) uniform Master's degree studies at the UL / other institution …………………..
2) I previously pursued an LLP Erasmus/ Erasmus+/Scholarship and Training Fund mobility for traineeships:
with/without scholarship granted in the ………………… academic year;
in the period (according to Confirmation of Stay) between ……….………and ………………… ;
in the host institution named …………………………………………………………………
country: …………………………………………………during:
a) first-cycle studies at the UL / other institution ………………………………………………………
b) second-cycle studies at the UL / other institution …………………………………………………………
c) third-cycle studies at the UL / other institution ……………………………………………………………
d) uniform Master's degree studies at the UL / other institution ……………………………………………
3) I have never pursued student mobility for studies or traineeships within the framework of LLP Erasmus/Erasmus+/Campus Europae/Scholarship and Training Fund
4) I have been qualified for Student mobility for Studies from the University of Lodz within the Erasmus+ in 2015/16 academic year to the host institution ………………...... in ...... (country name).
Date and signature of the Student: ......
Data of contact person staying in Poland, to be contacted in emergency:
Name and surname:......Address:......
Home phone number:......
Mobile phone number:......
date: ...... Student’s signature......
______
Decision on qualification for the Student mobility for Traineeship within the Erasmus+ programme in 2015/16 academic year
date: ......
signature of the Institutional Erasmus Coordinator