UNIVERSIDADE PRESBITERIANA MACKENZIE
REQUEST FOR ACADEMIC EXCHANGE
MOBILITY PROGRAM
Academic Year: 20____
Desired Period:
Cooperation Agreement
Erasmus Mundus
Free Mover
1 Semester
2 Semesters
Feb./Jul.
Aug./Dec.
DADOS DO ALUNO:
Full Name: __________________________________________________________________
Gender: ( ) F ( ) M Date of Birth (D/MM/YYYY) ____/____/_____
Adress: ________________________________________________________________________________________
ZIP Code: _______________________________________ Tel.: ( ) _______________________________________
City: ____________________________ Country: ___________________ Mob. ( ) ____________________________
Country: _________________ Nationality________________ State: ___________________ City:_________________
Passport Num.: ________________________ E-mail:____________________________________________________
ACADEMIC INFORMATION
Name of the Home Institution: _____________________________________________________________________
Address: ______________________________________________________________________________________
ZIP Code: ___________________________________ Phone. ( ) ________________________________________
City: _____________State:______________ Country: ________________Fax: ( ) ___________________________
Mobily Responsible:
Name: _____________________________________________
Stamp:
E-mail: _______________________________________________________________________
Pág. 1-3
COI – Coordenadoria de Cooperação Internacional e Internacional
Rua da Consolação, 896 – Ed. João Calvino - Térreo  Consolação  São Paulo - SP  CEP 01302-907
Tel.+ 55 (11) 2114-8186  www.mackenzie.br/coi.html  e-mail: [email protected]
UNIVERSIDADE PRESBITERIANA MACKENZIE
Name: ________________________________________________________________________________________
Home Institution: __________________________________________Course: ______________________________
( ) 1º Semester
( ) 2º Semester
Semester enroled: _________________
STUDY PROGRAM
Code
Discipline/ Course
_________________________
Hour
__/___/___
Student
____________________________
Date
Course
___/___/___
Responsible of Mobility
Date
HOME UNIVERSITY
We confirmed that the Study Planning proposed was approved.
_______________________________
___/___/___
International Departamental Coordinator
Date
_____________________________ ___/___/____
International Institucional Coordinator
Date
UNIVERSIDADE PRESBITERIANA MACKENZIE
We confirmed that the Study Planning proposed was approved.
_______________________________________
Assinatura da Coordenação do Curso na UPM
___/___/___
Data
_____________________________ ___/___/___
Assinatura da Direção do Curso
Data
*Free Movers oriundos de IES sem a celebração de convênio com a UPM, faz-se necessário a aprovação
abaixo do Pró-Reitor de Graduação da UPM.
Assinatura do Pró-Reitor de Graduação
______________________________ Data ___/____/____
Pag. 2-3
COI – Coordenadoria de Cooperação Internacional e Internacional
Rua da Consolação, 896 – Ed. João Calvino - Térreo  Consolação  São Paulo - SP  CEP 01302-907
Tel.+ 55 (11) 2114-8186  www.mackenzie.br/coi.html  e-mail: [email protected]
UNIVERSIDADE PRESBITERIANA MACKENZIE
Commitment Agreement TO International Students
I, ______________________________________________________________________, enrolled in the
Institution _______________________________________________, regular student of that IES, of course
______________________________________ want to apply at Mackenzie University as a student by the
Cooperation Agreement or Free Mover and I promise to attend 1 or 2 semester (s) in 2016 and being aware and
in accordance with the following conditions for my participation to the program:
1. The final improvement of the syllabus prepared by the international student is made by the Academic Unit at
Universidade Presbiteriana Mackenzie(UPM);
2. I do promise to send a digital copy of International Insurance within 10 days after sending the e-mail to UPM
with a digital copy of the Letter of Acceptance;
3. I understood to be aware about the deadlines for the UPM exchange schedule, notably the sending of
documents and attendance at the orientation meeting;
4. Report by formal email to the COI about anything about the exchange program by [email protected]
5. It is the responsibility of the student to solve any issues academic issues in their academic unit at UPM, with
support from international teacher of the Academic Unit;
6. I agree to cancel my mobility and return to my home country without any damages or charge to Mackenzie if
they do not fulfill the study plan or if you receive any disciplinary punishment;
7. If I lost my TIA card (Student Card) I am responsible for the payment of a fee of R $ 10.00 (Ten Reais) to the
Financial Assistance of Students (AFA) to get a new card;
8. Any study plans need to be approved by the course coordinator in the home institution before being forwarded
to the AU Internship Coordinator at UPM.
9.I am responsible for my registration with the Federal Police in São Paulo to do my CPF( Social Security) ,
indispensable for the realization of my enrollment at UPM
Specific for a Free Mover candidate:
1. I fit in in the items above, plus:
2. I am aware of the payment of tuition and fees for the chosen semester;
3. I am aware that the fees may change from one semester to another without notice;
4. I am aware that I will pay R $ 10.00 for issuance of TIA card, and if lost, I am solely responsible for payment of
the fee to remove a duplicate card;
________ / _________ / _______ Date
______________________________________________________
Signature of Applicant
Pag . 3-3
COI – Coordenadoria de Cooperação Internacional e Internacional
Rua da Consolação, 896 – Ed. João Calvino - Térreo  Consolação  São Paulo - SP  CEP 01302-907
Tel.+ 55 (11) 2114-8186  www.mackenzie.br/coi.html  e-mail: [email protected]