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Application Form - Haute école en Hainaut
INCOMING Student Application Form Academic year 2….../2…... This application should be completed in BLACK and BLOCK letters in order to be easily copied / scanned and sent by email. SENDING INSTITUTION Name and full address :………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………………… .. ………………………………………………………………………………………………………………………………………………… . Teacher in charge of the exchange- Name, telephone/mobile, e-mail : ………………………………………………………………………………………………………………………………………………… . ………………………………………………………………………………………………………………………………………………… . ………………………………………………………………………………………………………………………………………………… . Institutional coordinator – Name, telephone/mobile, e-mail : ………………………………………………………………………………………………………………………………………………… . ………………………………………………………………………………………………………………………………………………… . ………………………………………………………………………………………………………………………………………………… . STUDENT’S PERSONAL DATA Family name:………………………………………….… Date and place of birth:…………………………… Nationality:……………….…………………………….… Current address:……………………………….…….. ………………………………………………………………….. ………………………………………………………………….. Current address is valid until:………………….. Tel number:………………………………………………. Fax number:……………………………………..………. Email address:………………………………….………. First name(s):……………………………………………. Sex: M /F Permanent address (if different): ……………………………………………………. …………………………………………………... ………………………………………….……….. PROGRAMME ERASMUS+ FAME ERASMUS BELGICA OTHER (Please specify) : ………………………………… Label démarche Qualité LIST OF INSTITUTIONS WHICH WILL RECEIVE THIS APPLICATION FORM (in order of preference) Country Institution Period of study From To Duration of stay (months) No. of expected ECTS credits 1.……………………………….………….…. ……… ………. ……….. ………… ……………… 2. ………………………………………….…. ..……. ……….. ……….. ………… ……………… 3. ………………………………………….…. ……… ……….. ……….. ………… ……………… HOST DEPARTMENT Campus Economique in Tournai : Droit Secrétariat de Direction Tourisme Campus Pédagogique in Mons & Tournai Régent Instituteur préscolaire (only in Tournai) Instituteur primaire Educateur spécialisé Campus Social in Mons : Assistant(e) social(e) Conseiller(e) social(e) Campus Technique in Mons : Bachelor (BA2 – BA3) Biotechnique Electronique Informatique et Systèmes Techniques graphiques Master : Industrial Engineering (MA1-M2) Construction Energie et Environnement Génie civil et Bâtiment Géomètre Informatique Multimédia et Génie logiciel Systèmes temps réel et embarqués PREVIOUS and CURRENT STUDIES Diploma/Degree you already have:……………………………………………………………………………………….. Diploma/Degree for which you are currently studying:………………………………………………….…….. Number of higher education study years prior to departure abroad:…………………………………... Number of ECTS validated in higher education prior to departure abroad:………………………..... Have you already studied abroad ? Yes No If yes, when and where (name of institution, city, country)?:………………………………………………. …………………………………………………………………………………………………………………………………………………… Expected ECTS credits to be validated abroad : …………………………………………………………………………………………………………. The attached transcript of records includes full details of previous and current higher education study (subjects and marks obtained). Details not known at the time of application will be provided at a later stage. Label démarche Qualité WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant) Work experience / position Firm /organization Dates Country ……………………………………… ………………………………………………………………… …………………………… …………………… ……………………………………… ………………………………………………………………… …………………………… …………………… ……………………………………… …………………………………………………………………. …………………………… ……………………. LANGUAGE COMPETENCE Native language: ……………………………………………………………………………………………………………….. My French linguistic level is: B1 – B2 My English linguistic level is : B1 – B2 My Spanish linguistic level is : B1 – B2 Are you interested in free French courses? YES - NO Please note that all the courses are taught in French, except foreign language courses Do you want to book a room ? : YES - NO Date of arrival in Mons - Tournai :..............................Period of stay:....... ............ months Term dates: from.......................... to ............................ I, the undersigned ......................................................(Post)................................... Certify that the application of the student mentioned above has been approved by the Academic Authorities of the Sending Institution. I approved the stay of the student at the Institute of Higher Education of the French-speaking Community during the academic year 2……..-2…..…. Place.................................., date........................................ Student’s signature Person in charge of the exchange Name and post………………………....... ............................................... (Signature) ………………………………… Official stamp of the sending institution This document, completed and signed, must be sent to: Haute Ecole de la Communauté française en Hainaut Cellule des Relations Internationales et Extérieures 4 rue Pierre-Joseph Duménil B-7000 MONS DEADLINES: June 15th for the first semester December 15th for the second semester (No application accepted after the deadline) Label démarche Qualité Attention: The application will not be accepted without the ECTS learning agreement completed. RECEIVING INSTITUTION We hereby acknowledge receipt of the application, the proposed learning agreement and the candidate’s Transcript of records. The above-mentioned student is provisionally accepted at our institution not accepted at our institution Departmental coordinator’s signature Institutional coordinator’s signature …………………………………………………………... …………………………………………………………… Date: ……………………………………………….. Date: ………………………………….…………… Espace réservé à la Cellule R.I.E.: Date de réception : Remarque(s) : Label démarche Qualité
