UNIVERSITA’ DEGLI STUDI DI FIRENZE – I FIRENZE01
ERASMUS
TEMPUS
ALFA
INTERUNIVERSITY COOPERATION AGREEMENTS
INTERFACULTY EXCHANGE
STUDENT MOBILITY PROPOSAL & ENROLMENT FORM
ACADEMIC YEAR
20__ / 20__
FIELD OF STUDY
:
_________
(DEGREE/DIPLOMA COURSE IN:________________________)(photo)
This application should be completed in BLACK CAPITAL LETTERS in order to be easily copied and/or telefaxed.
HOME INSTITUTION CODE:
...Name and full address
:... ... ...……Departmental coordinator of the programme:
...telephone:
...telefax:
...e-mail:
Institutional coordinator of the programme:
...telephone :
...telefax :
...e-mail:
COORDINATOR’S SIGNATURE STAMP OF THE HOME INSTITUTION
……….………...
………Date……..………
(
APPLICATION NOT ACCEPTED IF MISSING
)
STUDENT’S PERSONAL DATA
Registration N.:
...Family name:
...First name(s):
...Sex
:...Date of birth:
...Place of birth:
………Nationality:
... Data di nascita Luogo di nascita CittadinanzaCurrent address:
...Permanent address (if different):
... ... ... ... ...……...Tel.
...Tel.
...:
Host Institution
Istituzione ospitanteUniversità degli Studi di Firenze Faculty: MEDICINE
Erasmus & International
Relations Coordinator of the
programme:
Prof. R. CorradettiCountry
PaeseItaly
Period of study
Periodo di studio(full dates please)
from
(da)to
(a).../.../...to.../.../...
Duration of stay
(
n° of months)
Durata del soggiorno (n°mesi) ...expected ECTS
credits
crediti ECTS previsti ...RECEIVING INSTITUTION
NOT to be filled in by the applicant!
We hereby acknowledge receipt of the application.The above-mentioned student is:
provisionally accepted at our institution.
not accepted at our institution.
ERASMUS & International Relations Coordinator
of the programme or ERASMUS delegate Erasmus / International Relations Office
Signature:
………STAMP
Date:
………...Date:
...DATA FOR ENROLMENT:
To be completed by Florence Secretariat
Date of beginning of the study period at the University of Florence:
...ERASMUS/International Relations Coordinator of the programme or ERASMUS delegate
UNIVERSITA’ DEGLI STUDI DI FIRENZE – I FIRENZE01
ERASMUS
TEMPUS
ALFA
INTERUNIVERSITY COOPERATION AGREEMENTS
INTERFACULTY EXCHANGE
Name of student: ...
Registration N°: ...
Home Institution:...
Country : ...
Main reasons why I wish to study abroad:
If necessary, continue on a separate sheet
CURRENT AND PREVIOUS STUDY
Diploma/degree for which I am currently studying: ...
Duration of course: ... years Years of study prior to departure abroad : ...
I have already studied abroad Yes
No
If Yes, when? ...
At which institution?...
WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant)
Type of work experience Company / organization dates country
……….. ……….. ………… ………
……….. ……….. ………… ………
Unique deadline for all applications: 31
STMay.
Please send all Medical Faculty mobility applications to:
International Relations Secretariat,
Erasmus Service
Faculty of Medicine,
NIC - Padiglione H3
2nd floor - room no. 218/219
Largo Brambilla, 3 - 50134 Florence, Italy
for pdf. applications
:
erasmusmedicina@polobiotec.unifi.it
Fax: +39 055 4598 931. Phone: +39 055 4598 793
LANGUAGE COMPETENCE
Languages
Mother tongue
Excellent
Good
Fair
Italiano
English
Français
Deutsch
Español
Other:
………...Other:
...UNIVERSITA’ DEGLI STUDI DI FIRENZE – I FIRENZE01
ERASMUS
TEMPUS
ALFA
INTERUNIVERSITY COOPERATION AGREEMENTS
INTERFACULTY EXCHANGE
ECTS - EUROPEAN CREDIT TRANSFER SYSTEM (if adopted)
LEARNING AGREEMENT
:
COURSES page n°___
If you need more than one page for courses, please reprint this form (indicate 1/2 & 2/2). Each page must be signed and stamped.
ACADEMIC YEAR
20__ / 20__
Name & Surname of Student: ... Registration ...
Home Institution:... Country : ...
Host Institution: I FIRENZE 01 Country: ITALY Faculty of Medicine: SpecificDegree for which you are studying:……… I SEMESTER and/or II SEMESTER Total n° months:____
For which Course year will you be in Florence? I , II , III , IV , V , VI
ECTS Code, if any
COURSE UNIT
Y / SAnnual, semestral ECTS Credits
Total expected credits
Student’s signature : ...Date……….
HOME INSTITUTION
LEARNING AGREEMENT
We confirm that this proposed programme of study is approved. Date:
……….
Erasmus/International Relations Institutional/Departmental Coordinator. Academic tutor
Name
(nome):
...Name
(nome):
...
Signature
(firma):
...Signature
(firma):
...………
HOST INSTITUTION (I FIRENZE 01)
LEARNING AGREEMENT
We confirm that this proposed programme of study is approved. Firenze
,………..
Erasmus/ International Relations Academic Tutor - Name
(nome)………
Erasmus delegate: PROF. RENATO CORRADETTI
ERASMUS
TEMPUS
ALFA
INTERUNIVERSITY COOPERATION AGREEMENTS
INTERFACULTY EXCHANGE
ECTS - EUROPEAN CREDIT TRANSFER SYSTEM (if adopted)
LEARNING AGREEMENT
:
CLINICAL ROTATIONS page n° __
If you need more than one page for rotations, please reprint this form (indicate 1/2 & 2/2). Each page must be signed and stamped.
ACADEMIC YEAR
20__ / 20__
Name of student: ... Registration ...
Home institution:... Country : ...
Host institution: I FIRENZE 01 Country: ITALY Faculty of Medicine:SpecificDegree for which you are studying:………
I SEM and/or II SEM Total n° months:………
Which Course year will you do in Florence? I , II , III , IV , V , VI
ECTS Code, if any
CLINICAL ROTATIONS
Please specify each rotation you wish to do.
A good knowledge of Italian is required before starting your rotations
N° of weeks (maximum 4 weeks per rotation) ECTS Credits crediti ECTS ... ... ...
... ...
... …...
…... …...
…... …...
…... …...
…... …...
…... …...
…...
Total expected credits ………
Student’s signature : ...Date……….
HOME INSTITUTION
LEARNING AGREEMENT
We confirm that this proposed programme of study is approved. Date:
………..
Erasmus Institutional/Departmental Coordinator Academic tutor
Name
(nome):
...Name
(nome):
...STAMP...
Signature
(firma):
...Signature
(firma):
...
HOST INSTITUTION (I FIRENZE 01)
LEARNING AGREEMENT
We confirm that this proposed programme of study is approved. Firenze
,………..
Erasmus/ International Relations Coordinator of the programme - Name
(nome)………
Erasmus delegate: PROF. RENATO CORRADETTI
UNIVERSITA’ DEGLI STUDI DI FIRENZE – I FIRENZE01
ERASMUS
TEMPUS
ALFA
INTERUNIVERSITY COOPERATION AGREEMENTS
INTERFACULTY EXCHANGE
ECTS - EUROPEAN CREDIT TRANSFER SYSTEM (if adopted)
CHANGES TO ORIGINAL LEARNING AGREEMENT
to be used only after arrival in Florence
ACADEMIC YEAR
20__ / 20__
Name of student: ... Registration ...
Home institution:... Country : ...
Host institution: I FIRENZE 01 Country: ITALY Faculty of Medicine:SpecificDegree for which you are studying:………. I SEMESTER and/or II SEMESTER Total n° months:………
Which Course year will you do in Florence? I , II , III , IV , V , VI
ECTS Code, if any Course Unit deleted added
ECTS Credits Crediti ECTS ... ... ... ... ... .. ... ... ... ... ... ... ... ... ... ... ………. ... ………...….. ……… ………. ... ………...….. ……… ……….
