Erasmus Programme
Student mobility for study	

STUDENT APPLICATION FORM
ACADEMIC YEAR 2010/2011
(Photograph)

FIELD OF STUDY:      

SENDING INSTITUTION
Name and full address: University of South Bohemia in České Budějovice
                                    Branišovská 31, 370 05 České Budějovice, Czech Republic 
Erasmus ID code:         CZ CESKE01	
Faculty/Department coordinator – name, telephone and telefax number, e-mail
Daniela Grubhofferová, tel.: +420 387 774 818; fax: +420 387 774 812; daniela@ff.jcu.cz
	
Institutional coordinator - name, telephone and telefax number, e-mail
Andrea Augustinová; tel.: +420 389 032 029; fax: +420 385 310 373; augustin@jcu.cz 	

STUDENT’S PERSONAL DATA (to be completed by the student applying)
Family name:      	First name (s):      	
Date of Birth:      	Place of Birth:      	
Sex:      	Nationality:	
Current address:	Pernament address (if different):	

		
Tel.:      	E-mail:      	

LIST OF INSTITUTIONS WHICH WILL RECEIVE THIS APPLICATION FORM (in order of preference):
Institution	Country	Period of study	Duration of stay (month)	No. of expected ECTS credits	
		from	to			
     
	     	     	     	     	     	

Name of student:	     	

Briefly state the reasons why you wish to study abroad?
     

LANGUAGE COMPETENCE
Mother tongue:	     	
Other languages:	Level	
     	□ excellent	□ good	□ satisfactory	□ poor	
     	□ excellent	□ good	□ satisfactory	□ poor	
     	□ excellent	□ good	□ satisfactory	□ poor	

WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant)
Type of work experience	Firm/organization	Dates	Country	
		from	to		
     					
     					

PREVIOUS AND CURRENT STUDY
Diploma/degree for which you are currently studying (Bc. Mgr. PhD.):       	
Number of higher education study years prior to departure abroad:      	
Have you already been studying abroad?                Yes             No 	
Yes, when? at which institution?	

The attached Transcript of records includes full details of previous and current higher education study. Details not known at the time of application will provided be at a later stage.

Do you wish to apply for a mobility grant to assist towards the additional costs of your study period abroad?         Yes           No 	

RECEIVING INSTITUTION
We hereby acknowledge receipt of the application, the proposed learning agreement and the candidate’s Transcript of records.	
The above-mentioned student is	 provisionally accepted at our institution
 not accepted at our institution	
Stamp of university and Departmental /Institutional coordinator’s signature:

Date: