Practical placement -  STUDENT APPLICATION FORM
ERASMUS PROGRAMME
Academic year: 2021/2022
Subject area: ………………………………
This application should be completed in BLACK in order to be easily copied and/or telefaxed.

SENDING INSTITUTION
Name and full address: 	UNIVERSITY OF SZEGED			Int. code: HU SZEGED01 
			H-6720 SZEGED, DUGONICS TÉR 13.
Departmental coordinator - name, telephone and telefax numbers, e-mail box 
.........................................................................................................................................

HOST ORGANISATION:
Institution	Country	Period of study
from       to	Duration of stay (months)	Evaluation 
(expected ECTS credits or
Required documents for recognition)	

 ...............................	
.................	
............	
............	
.................................	
........................Credits
…………………Documents	

STUDENT’S PERSONAL DATA (to be completed by the student applying)

Family name: ..................................................	
First name(s): .................................................	
Date of birth: .................................................		
Sex: ............ Nationality: ...............................		
Place of birth: ................................................		
Current address: ............................................
.......................................................................	Permanent address (if different): .....................
..........................................................................	
Phone: ...........................................................	Phone: ..............................................................	
E-mail address: ..............................................................……………………………………….	

LANGUAGE COMPETENCE
Mother tongue: ……………………………………..	
Other languages:……………………………………….
……………………………………………………………	

WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant)
Type of work experience

……………………...	Firm/organisation

……………………...	Dates

……………………...	Country

……………………...	
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: …………………………………….	

Student’s signature: ...........................................................................Date: ……………………............................................

HOST ORGANISATION
Hereby we acknowledge 	
	 the receipt of the application,	
	 the proposed Training agreement and	
		
The above-mentioned student is	 provisionally accepted at our organisation	
	 not accepted at our organisation	
Coordinator’s signature:
……………………………………………………………..                Date: ……………………………………..