Charles University in Prague 

STUDENT APPLICATION FORM

Please send either to the relevant Faculty Co-ordinator (http://www.cuni.cz/UK-1008.html#5) or to the European Office, Charles University, Ovocný trh 3, 116 36 Praha 1, Czech Republic

(Photograph)

LLP – ERASMUS PROGRAMME

ACADEMIC YEAR 2008/2009
FIELD OF STUDY:	     	

SENDING INSTITUTION: Charles University in Prague (CZ_PRAHA07)
	
Ovocný trh 3/5, 116 36 Praha 1, Czech Republic

Institutional coordinator - name, telephone and telefax numbers, e-mail box: 
Mgr. Michal Maršálek, DiS. Phone +420 224 491 310, FAX: +420 224 229 487
E-mail: michal.marsalek@ruk.cuni.cz	
Department or Faculty co-ordinator:	
Name:	     	Telephone:	     	
E-mail:	     	Fax:	     	
	
STUDENT’S PERSONAL DATA
Family name(s):	First name(s):
	
     	     	
Date of Birth:	     	Sex:		Permanent address	
Place of Birth:	     	     	
State Citizenship:	     	     	
E-mail:
     	     	
	     	
Tel.:	    	Country:	     	

RECEIVING INSTITUTION:	     	

From
dd/mm/yyyy	To
dd/mm/yyyy	Duration of stay (months)	N° of expected ECTS credits	
     	     	     	     	

Name of student: 	     	
Sending institution:	Charles University in Prague (CZ_PRAHA07)
:	

Briefly state the reasons why you wish to study abroad? 	
     	
     	
     	

LANGUAGE COMPETENCE
Communication language(s)	I am currently studying this language	I have sufficient knowledge to follow lectures	I would have sufficient knowledge to follow lectures if I had some extra preparation	
     	Yes 	Yes 	Yes 	
     	Yes 	Yes 	Yes 	
     	Yes 	Yes 	Yes 	
				
WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant)
Type of work experience	Firm/organisation	Dates	Country	
     	     	     	     	
     	     	     	     	
     	     	     	     	
				
PREVIOUS AND CURRENT STUDY
Diploma/degree for which you are currently studying:		
Number of higher education study years prior to departure abroad:	     	
Have you already studied abroad?	Yes 	
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 be provided at a later stage.	

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
	
Departmental coordinator’s signature	Institutional coordinator’s signature

Date:		Date:		

LEARNING AGREEMENT

LLP – ERASMUS PROGRAMME

Name of student: 	     	
Sending institution:	Charles University in Prague (CZ_PRAHA07)

DETAILS OF THE PROPOSED STUDY PROGRAMME ABROAD/LEARNING AGREEMENT

RECEIVING INSTITUTION:      	

Course unit code (if any) and page no. of the information package
	Course unit title (as indicated in the information package)
	Number of ECTS credits

1.	     	     	     	
2.	     	     	     	
3.	     	     	     	
4.	     	     	     	
5.	     	     	     	
6.	     	     	     	
7.	     	     	     	
8.	     	     	     	
9.	     	     	     	
10	     	     	     	
11	     	     	     	
12	     	     	     	
13	     	     	     	
14	     	     	     	
15	     	     	     	

Student’s signature:
	Date: 	

SENDING INSTITUTION: Charles University in Prague (CZ_PRAHA07)	
We confirm that the proposed programme of study/learning agreement is approved.	
Departmental coordinator’s signature	Institutional coordinator’s signature	
		
Date:		Date:		

RECEIVING INSTITUTION	     	
We confirm that this proposed programme of study/learning agreement is approved.	
Departmental coordinator’s signature	Institutional coordinator’s signature	
		
Date:		Date: