Mobility Direct application form

MOBILITY DIRECT APPLICATION FORM

PLEASE USE CAPITAL LETTERS

PERSONAL DATA
Name:	Surname:
Date of Birth:	Male [ ] Female [ ]
I wish to register for the following semester (mark one): Winter [ ] Summer [ ]
Nationality:
Home Address:
City:	Postcode:
Country:	Home Tel.:
E-mail:	Fax:
Person to contact in Name: case of emergency Tel.:

Home University:
Address:
City:	Postcode:
Country:	Tel.: Fax:
Field of Study:	Year of Study:
Mobility Direct Coordinator: Tel.: E-mail: Fax:
LANGUAGE SKILLS
Please, specify knowledge of other languages as: GOOD, FAIR, POOR
Mother Tongue: Other Languages: Reading Writing Speaking Understanding 1. ___________ __________ ________ __________ ___________ 2. ___________ __________ ________ __________ ___________ 3. ___________ __________ ________ __________ ___________

Please, give a brief information about your reasons for studying at the University of Lodz.

Aplicant’s Signature:

Date:

Space for administrative purposes:

Дата добавления: 2015-08-27