CONVENTION Université OTTAWA – Canada 20 …./20 …. Incoming

CONVENTION
Université OTTAWA – Canada 20 …./20 ….
Incoming Student Application Form
INSTITUT DE PSYCHOLOGIE
Etudiant(e) / Student’s Personal data :
Nom / Legal family name: …………………………………………
(photographie)
Prénom / First name:…………………………………………………
Sexe / Sex : F ο
Mο
Date de naissance / Date of birth:……………
Nationality :…………………..
IC or Passport :…………………………………………………………………
Current Address (Street, Postal Code, City, Country) :……………………………………………………
………………………………………………………………………………………………………….
℡ (Country Code, Area Code, Number):………………………………………. Fax:………………………………..
e-mail :………………………………………………………………………………..
Permanent Address (if different).............................................................................................................................
…………………………………………………………………………………………………………………………………
Adresse et nom de la personne à prévenir en cas d’urgence/ name and Address of contact person in case of
emergency :………………………………………………………………………………………………………………….
℡(Country Code, Area Code, Number) ………………………………………………………………………………………..
e-mail:………………………………………………………………………………………… Parenté/Relationship :………………..
Etablissement d’origine / Sending Institution :
Nom / Name :…………………………………..…………………………………………………………
Pays / Country :……………….…………………………ISO Code :…………………………………..
Institutional/Departmental Co-ordinator (Name, Tel, Fax, e-mail):…………………………….……
………………………………………………………………………………………………………..
Etudes / Studies :
Dernier diplôme obtenu / Last Degree - Diploma : ………………………………………………..
Année en cours / Expected completion year :……………………………………………..
Niveau de langue / Language Competence :
Langue maternelle / mother tongue : …………………………………………
Langue pratiquée /
Niveau faible /
Niveau moyen /
known language
elementary level
intermediate level
Français / French
ο
ο
Anglais / English
ο
ο
Autre / other…………..
ο
ο
Date :…………………………
Niveau avancé /
advanced level
ο
ο
ο
Student’s signature :………………………………
Programme d’études à Paris Descartes / Study program in Paris Descartes – Code F PARIS 05:
UFR ou Faculté :………………………………… Département / Speciality :………………………
Niveau d’études demandé:
L1S1 ο L1S2 ο L2S3 ο L2S4 ο L3S5 ο L3S6 ο (Niveau Intermédiaire) M1S1 ο M1S2 ο (Niveau
Avancé) Autres (préciser) :………………………………………..
Durée du séjour à Paris Descartes / Intended period of study :
Durée d’étude / period of study :………..mois / months
π Premier semestre / First semester
de / From……………………… à / To…………………………
π Second semestre / Second semester de / From……………………….à / To…………………………
π Année complète / Full year
de / From………………………à / To………………………….
Université OTTAWA - Canada
Nom / Legal family name: ………………………………………………………….…………………
Prénom / First name:……………………………………………………………………………...……
Liste des cours envisagés / Details of the Proposed study programme abroad Learning agreement : Année 20…../20…..
Code du
cours
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Intitulé du cours
ECTS
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Stage hospitalier /
Discipline / Field of study
Durée / Duration
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Crédits ECTS
I agree that these data will be stored :
Student’s signature :
Date :…………………………
Etablissement d’origine / Sending Institution
Nous confirmons que ce programme d’études/contrat d’études est approuvé.
We hereby confirm that the proposed programme of study/learning agreement is approved.
Signature du coordonnateur de département/Faculté
Department/Faculty Coordinator’s
signature and stamp of sending institution
Date :………………………………………..
Signature du responsable Erasmus
de l’Etablissement
Institutionnal Erasmus Coordinator’s
signature and stamp of sending institution
Date : ……………………………….
Université Paris Descartes – Institut de Psychologie
Nous confirmons que ce programme d’études/contrat d’études est approuvé.
We hereby confirm the proposed programme of study is approved.
Signature du responsable pédagogique
Signature du coordinateur Erasmus
de la Faculté / UFR
Date :………………………………………..
Date : ……………………………….
Please return the Application Form and the approved Learning Agreement abroad with all others documents to the ERASMUS
Administrative Responsible at the receiving Faculty in the University Paris Descartes before March 31 for the first semester and
before October 31 for the second semester to:
Institut de Psychologie - bureau des relations internationales– 71 avenue Edouard Vaillant - 92100 Boulogne-Billancourt –
France
+33 1 55 20 57 76
Université OTTAWA - Canada
Nom / Legal family name: ………………………………………………………….…………………
Prénom / First name:……………………………………………………………………………...……
Modification du contrat d’études/ Changes to the original proposed study programme abroad/learning
agreement: Année 20…../20…..
First semester : ο
Second semester : ο
Code du
cours
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Intitulé du cours / name of the course
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Signature de l’Etudiant(e) :
Cours
supprimé /
course
deleted
Cours
ajouté /
course
added
ο
ο
ο
ο
ο
ο
ο
ο
ο
ο
ο
ο
ο
ο
ο
ο
ο
ο
ECTS
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Date :…………………………
Etablissement d’origine / Sending Institution
Nous confirmons que les modifications au programme d’études/contrat d’études sont approuvées.
We hereby confirm the above-listed changes to the initially agreed programme of study/learning
agreement are approved.
Signature du coordonnateur de département/Faculté
Department/Faculty Coordinator signature
and stamp of sending institution
Signature du responsable Erasmus
de l’Etablissement
Institutionnal Erasmus Coordinator’s
signature and stamp of sending
institution
Date :………………………………………..
Date : ……………………………….
Université Paris Descartes – Institut de Psychologie
Nous confirmons que les modifications au programme d’études/contrat d’études sont approuvées.
We hereby confirm the above-listed changes to the initially agreed programme of study/learning
agreement are approved.
Signature du responsable pédagogique
Date :………………………………………..
Signature du coordinateur Erasmus
de la Faculté / UFR
Date : ……………………………….