Worldwide Alliance programme Application form 2013

 Worldwide Alliance programme Application form 2013 May 13th – September 13th, 2013 Photo School: ………………………………………..…………… Nom / Surname : ………………………………………..………………………..……. Prénom / First name : ………………………………………….…………………….. Homme / Male  Femme / Female  Date de naissance / Date of birth : ………………………………...………........………………………
Nationalité / Nationality : …………………………………………………………........………………………
Adresse / Address………………………………………………………………..………………….………………… …………………………………………………………………………………………………………………………….…… Code postal / Zip code : ……………… Ville / City : .................................................... Pays / Country: ………………………………………………………………………………….…………………….. Téléphone / Telephone : …………………………………Portable / Mobile………………….…….… E-­‐mail : ………………………………………..……………………………………………………………………………. Vos contacts à l’Institut Paul Bocuse Your contacts at the Institut Paul Bocuse : Sophie Reynaud, Alliance program Coordinator: [email protected] -­‐ 00.33.(0)4.72.18.09.86 Eléonore Vial, Dean and the Alliance Program Director: [email protected] -­‐ Château du Vivier – 69130 Ecully cedex – France -­‐ Tel : 33/472 18 02 20 -­‐ www.institutpaulbocuse.com ♦Situation scolaire /School attended ♦ Diplôme préparé / Degree-­‐ Diploma in preparation : Année ou semestre actuellement suivi – Year or semester currently attending ……………………………………………………………………………………………….…………………………………. ……………………………………………………………………………………………………………………………………. ♦ Autres diplômes / Other degree-­‐diploma Année-­‐Year ………….. Diplôme-­‐diploma result ……………………………………………. Etablissement – School ………………………………………. ………….. ……………………………………………. ………………………………………. ………….. ……………………………………………. ………………………………………. ♦ Langues vivantes / Language skills * abréviations à indiquer dans les colonnes/*abbreviations to use in the columns : F : courant-­‐ Fluent I :Intermediate SL : Niveau scolaire-­‐ school level (SL + ou SL-­‐) B : débutant – Beginner Langue maternelle Expression écrite* Expression orale* Mother tongue Written language Spoken language Français French Anglais English Espagnol Spanish Autres Others ♦ Exprimez en quelques mots, votre motivation pour ce programme à l’Institut Paul Bocuse en français Express in a few word, your interest and motivation for this culinary program at Institut Paul Bocuse in french -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ Assurance médicale/ Health insurance policy: To begin the program you must have a international health insurance policy. This Insurance covers all accident and injuries caused to yourself (falls cuts and burns) during your stay. This policy must cover your medical costs, hospitalization, and eventual repatriation. You must provide proof of this insurance prior to the start of the course. Hébergement dans la résidence de l’Institut / Accommodation in the student hall of residence : Les chambres sont attribuées en fonction des confirmations d’inscription Rooms are assigned on a first-­‐ come, first-­‐ served basis, on reception of registration forms and deposit Oui / yes -­‐Souhaitez-­‐vous une chambre individuelle? Would you like a single room? -­‐Souhaitez-­‐vous une chambre double? Would you accept a double room (shared)? A reduced-­‐rate insurance policy through the Institute’s insurers is included in the fee (23€): it includes the third party insurance and the multi risk housing Insurance which are compulsory. Assurance Responsabilité civile -­‐ Third party Insurance: Insurance covering all accidents and injuries caused to a third party during your stay is mandatory. Assurance Habitation -­‐ Multi-­‐Risk Housing Insurance Multi-­‐risk insurance is compulsory for staying in the student housing. VISA : Attention. Vous recevrez votre lettre d’invitation pour l’ambassade seulement une fois les frais de scolarités acquittés. Il faut compter en moyenne 2 de mois de délai pour l’obtention de votre visa. Warning : you will get your invitation letter for the embassy only once the fee paid. You have to count around 2 full months of delay for obtaining your visa. PAIEMENT de L’INSCRIPTION : échéance le 13 Mars 2013 TUITON FEES PAYEMENT : to be paid before March 13th, 2013 A retourner / please, send: [email protected] Je soussigné(e) (nom-­‐prénom) / I the undersign (first name – last name) ……………………………………………… Ecole Membre / School Member : Règle mon inscription / Pay the tuition fees : o Par carte bancaire / by credit card o Visa o MasterCard / Eurocard n°…………………………………………………………………… Expirant le / expiration date …………/…………../………….. Date de prélèvement / charging date : …………/…………../………….. J’autorise l’Institut Paul Bocuse à débiter la somme de 4.973 € (quatre mille neuf cent soixante treize euros) / I authorize the Institut Paul Bocuse to charge my credit card for an amount of 4.973 € (four thousand and nine hundred seventy three euros) o Par virement bancaire / by bank transfer – Merci de preciser le nom & prénom du canditat sur le virement – thanks to specify your full name on the bak transfer Banque BNP PARIBAS BNPPARB LYON AG CENTRALE (02249) Code 30004 – 01428 -­‐ 00010024809 -­‐ 09 Numéro de compte bancaire international – IBAN FR 76 3000 4014 2800 0100 2480 909 – Institut Paul Bocuse Hôtellerie et Arts Culinaires Code d’Identification bancaire -­‐ BIC / BNPAFRPPLPD Date & Signature : Pièces à joindre obligatoirement au dossier de candidature Ø
The following documents must be enclosed with the application form: ♦Votre CV en français / your CV in French ♦ Copie de votre passeport / Copy of your passport ♦ Le justificatif de votre assurance médicale internationale / Certificate stating legal, international social & medical Insurance ♦ Un Certificat médical d’aptitude au métier la cuisine / Medical cerificate to garanty you are apt to work in kitchen ♦ Le document «Paiement de l’inscription» dument rempli /Tuition fee paiement document filled Je certifie avoir pris connaissance des conditions générales du programme (contenu et règlement intérieur de l’Institut Paul Bocuse) et les accepte telles qu’elles sont présentées. I herewith confirm that I have read the general conditions of the program (contents and rules of the Institut Paul Bocuse) and that I agree with them. Lieu & date / Place and date : Signature de l’étudiant / Candidate's signature : Vos contacts à l’Institut Paul Bocuse Your contacts at the Institut Paul Bocuse : Sophie Reynaud, Alliance program Coordinator: [email protected] -­‐ 00.33.(0)4.72.18.09.86 Eléonore Vial, Dean and the Alliance Program Director: [email protected] -­‐ Château du Vivier – 69130 Ecully cedex – France -­‐ Tel : 33/472 18 02 20 -­‐ www.institutpaulbocuse.com