Fill and Sign the Continuous Service Agreement Form

Application form exchange students 2011/2012 If you would like to come to UAS Leiden as an (Erasmus) exchange student you have to fill in this application form (incl. Learning Agreement). Please consider the deadlines! After we have received your application, the international coordinator of the programme of your choice will check if you fulfil the requirements and if you can be admitted. If you are admitted we will send you a letter of acceptance. Please digitally fill in all the blanks and tick the appropiate boxes. 1. Personal details student First name Family name Street and number Postal code Place of residence Country of residence Nationality Date of birth Place of birth Country of birth Gender ( ) male ( ) female Marital status ( ) married ( ) unmarried Telephone number Email address Name of home institution and country Name of contact person at home institution1 Email address of contact person home institution I'm in my .......year of studies at my home ( )1st ( )2nd ( )3rd ( )4th institution Title of degree for which I’m currently studying is 2. Studies at University of Applied Sciences Leiden Autumn semester Title minor Start End Application deadline EC International Law and Beginning of September Beginning of February 15 May 2011 30 Put an X if you apply for this minor 1 Contact person should be the same person who signs this form for authorization (see item 7) and who signs the learning agreement. 1 European Union Law 2011 2012 Global Awareness Tailormade programme Social Work Last week of August 2011 Beginning of September 2011 Third week of 1 April 2011 January 2012 Beginning of 15 May 2011 February 2012 30 Title minor Start End Application deadline EC European Union Law2 Global Awareness Molecular Diagnostics International Business I International Business II3 Tailormade programme Social Work 13 February 2012 Third week of January 2012 13 February 2012 13 February 2012 7 May 2012 27 April 2012 15 November 2011 1 October 2011 15 30 Beginning of February 2012 Beginning of July 2012 15 November 2011 15 November 2011 15 November 2011 15 November 2011 30 Spring semester First week of July 2012 13 July 2012 27 April 2012 13 July 2012 Put an X if you apply for this minor 30 15 15 30 3. Motivation (please write down – use max. 250 words - why you choose to come to the University of Applied Sciences Leiden) ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ 4. Other important issues * I will arrange that I’m sufficiently insured for medical costs and liability cases in the Netherlands. 2 3 This minor can be combined with the minor International Business II It is advised to participate in International Business I before participating in International Business II. This is not mandatory. 2 * If I stay for more than 4 months I will register myself at the local municipality in the Netherlands (local municipality is called 'Gemeentelijke Basis Administratie' in Dutch). Registration is not necesssary if I stay for less than 4 months. * I do not have a police record. 5. Space for remarks ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ 6. Signature student I hereby declare that the information I provided, is correct. Date Place Signature student ...................................................... ...................................................... ...................................................... 7. Signature contact person home institution I hereby declare that ............................................... (please fill in name of student) is authorized to come to the University of Applied Sciences Leiden. He/she has sufficient knowledge of the English language4. Name contact person home institution ..................................................... Date ..................................................... Place ...................................................... Signature contact person home institution ...................................................... You should send this application form (incl. Learning Agreement with your signature and signature of your contact person home institution, copy of your passport/identity card and an original passport photo) to: University of Applied Sciences Leiden Team Internationalization & Diversity Ms Maureen Bergman Postbus 382 2300 AJ Leiden The Netherlands bergman.m@hsleiden.nl PLEASE CONSIDER THE APPLICATION DEADLINES! No rights can be derived from the content of this form. 4 At least IELTS score 6 or TOEFL 550 3 LEARNING AGREEMENT ACADEMIC YEAR 2011/2012 - FIELD OF STUDY: Name of student: Sending institution: Country: Receiving institution: University of Applied Sciences Leiden Country: The Netherlands DETAILS OF THE PROPOSED STUDY PROGRAMME ABROAD Title of courses/modules (please write down all courses Amount of EC and modules you would like to do) STUDENT Student’s signature ............................................................. Date: .................................................................. 4 SENDING INSTITUTION We confirm that this proposed programme of study / learning agreement is approved. Departmental coordinator’s signature .............................................................. Date:.................................................................. RECEIVING INSTITUTION We confirm that this proposed programme of study / learning agreement is approved. Departmental coordinator’s signature ............................................................... Date: .............................................................. 5