Université Paris-Est Marne-la

SRI-E
Service des Relations Internationales – Enseignements
Bâtiment Copernic - Bureau 0B058
Université Paris Est Marne-la-Vallée / UPEM
5, boulevard Descartes - Champs sur marne
77454 Marne-la-vallée Cedex 2
[email protected] / +33 1 60 95 70 61
UFAC APPLICATION FORM INTENSIVE FRENCH COURSES
Please TYPE IN all relevant fields. Areas marked with red borders are mandatory.
STUDENT PERSONAL DATA
Family Name
First Name
Gender
Date of Birth
Male
Female
Place of Birth
(city/country)
(dd/mm/yyyy)
Current address
(home country)
If different :
permanent address
(home country)
e-mail 1
e-mail 2
phone number
(with international codes)
Home University
PAYMENT CONDITIONS
Only by Bank Transfer in Euros made out to :
Université Paris-Est Marne-la-Vallée, 5 bd Descartes, Champs sur Marne, 77454 Marne-la vallée Cedex 2
IBAN : FR76 1007 1930 0000 0010 0047 561
Beneficiary Bank : Trésor Public, Trésorerie Générale de Seine Saint Denis, 93000 Bobigny
BIC (Bank Identifier Code) : BDFEFRPPXXX
All costs at transmitter’s charge; state clearly and in full your name, your home university and
“UPEM French Autumn Course”. Any cancellation should be notified by email at [email protected] by June 29th.
Refunds will not be given after this deadline.
By signing this form, I certify that I have provided complete and accurate answers to the questions on this application
form and I agree to respect the application process and the conditions of the program presented in "UFAC Information".
Date :
Signature :
Strictly by post to the address in the header of this form by :
- May 30th, 2014 (1st term/full year)