Rua de Santo Amaro, 34
1200 - 803 Lisboa, Portugal
Telf.: +351 213 964 086
Fax.: +351 213 950 567
E-mail: [email protected]
Site: www.estal.pt
ERASMUS+ STUDENT
APPLICATION FORM
ACADEMIC YEAR
Complete this form and send it to [email protected] | Please attach: curriculum vitae, academic resume and letter of intentions.
COUNTRY
HOME UNIVERSITY
PROPOSED DATES OF EXCHANGE
1ST SEMESTER
✔
2ND SEMESTER
3RD SEMESTER
✔
✔
PERSONAL INFORMATION (Please fill in this application form with capital letters.)
COURSE
Name
Date of Birth
-
Gender
-
✔
F
ID / Passport number
✔
M
Date of issue
Student’s Address
Postal code | Town
E-mail
Home Tel.
Mobile Tel.
Mother’s name
Father’s name
Mother Language
Other Languages
Knowledge of Portuguese
Beginner
✔
Intermediate
✔
Advanced
✔
Estabelecimento de Ensino Superior reconhecido pela Portaria n.º 920/90, de 29 de Setembro, com a denominação constante do aviso n.º 16012/2000 (2ª série),
de 17 de Novembro, instituído pelo Instituto Leonardo da Vinci, NIPC 504232410.
Rua de Santo Amaro, 34
1200 - 803 Lisboa, Portugal
Telf.: +351 213 964 086
Fax.: +351 213 950 567
E-mail: [email protected]
Site: www.estal.pt
ACADEMIC INFORMATION (Please fill in this application form with capital letters.)
Home University
Contact person at the home institution
Name of the coordinator at home university
Address
Telephone
Fax
Email
Date: ____/____/2015
Date: ____/____/2015
Student’s signature
Coordinator’s signature
Stamp of home university
Estabelecimento de Ensino Superior reconhecido pela Portaria n.º 920/90, de 29 de Setembro, com a denominação constante do aviso n.º 16012/2000 (2ª série),
de 17 de Novembro, instituído pelo Instituto Leonardo da Vinci, NIPC 504232410.