Université Paris-Est Marne-la
Transcription
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)