ERASMUS+ 
            STUDENT MOBILITY PROPOSAL
           ENROLMENT FORM
ACADEMIC YEAR   ………… / ……...
ANNO ACCADEMICO

FIELD OF STUDY (ISCED code): .............................................................................
CODICE ISCED	

(photo)	

This application should be completed in BLACK in order to be easily copied and/or telefaxed.
Si prega di compilare questa domanda in NERO per facilitarne la copiatura e/o la trasmissione via fax.n.b.: SCRIVERE IN stampatello o a macchina
	HOME INSTITUTION                                                                     CODE: ...................................................
Name and full address:..................................................................................................................................
                                            ...................................................................................................................................
                                            .........................................................................................................................................................……
Departmental coordinator of the programme:..................................................................................................
phone: ...........................................    fax: ........................................e-mail:.......................................
Institutional coordinator of the programme:......................................................................................................
telephone : ......................................telefax : ................................... e-mail :.................................................
COORDINATOR’S SIGNATURE                  STAMP OF THE HOME INSTITUTION or Erasmus Office                  
 ……………………………………...                 …………………………………………………………………….
                                                                                  (APPLICATION NOT ACCEPTED IF MISSING)	
	STUDENT’S PERSONAL DATA 	Registration N.: ..................................................
Family name: ..........................................	First name(s): ........................................................ Sex:...........
Cognome	Nome	Sesso
Date of birth: ...............................	Place of birth: ................................. Nationality:...................................
Data di nascita	Luogo di nascita	Cittadinanza
Current address: ........................................................  Permanent address (if different): ............................
...................................................................................  .................................................................................
...........................................................................  ................................................……............................
Tel.: ...........................................................................  e-mail.:..........................................................................	
	
Host Institution
Istituzione ospitante

UNIVERSITA’ di FIRENZE

School: Political Science “Cesare Alfieri”
Erasmus coordinator of the programme: …………………….	
Country
Paese  

Italy	Period of study
periodo

   from (da)          to (a)  

.................             ................	Duration of stay (months)

Durata del soggiorno (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
Confermiamo con la presente di aver ricevuto la domanda	                 Lo studente summenzionato
        provisionally accepted at our institution.                   not accepted at our institution.
                   provvisoriamente accettato/a presso la nostra istituzione.       non è accettato presso la nostra istituzione
Erasmus Coordinator	  
Il delegato Erasmus	  	 
Signature: ………………………………    STAMP
Date: …………………………………….	Date: .......................................	
	DATA FOR THE ENROLMENT:                                                                  To be filled in ONLY after arrival
Date of beginning of the study period at the University of Florence:  ............................................................

Erasmus coordinator of the programme or Erasmus delegate	 
Signature: ………………………………    STAMP                             Date: …………………………………….: 	

 	Name of student: ............................................................	Registration N°: ......................................
Nome e cognome dello studente	N° di matricola
Home institution:..............................................................................	Country : .....................................
Istituzione di  origine	Paese
Main reasons why I wish to study abroad:
Principali motivi dello studio all’estero
....................................................................................................................................................................
...................................................................................................................................................................
 If necessary, continue on a separate sheet	
	CURRENT AND PREVIOUS STUDY
STUDI  ATTUALI  E  PRECEDENTI 
Iscritto(a) al Corso di laurea/diploma in 
Diploma/degree for which I am currently studying: ......................................................................................
Durata legale del corso
Duration of course: .........  years              Years of study prior to departure abroad : .....................................
I have already been studying abroad.                                      Yes         No  
Precedenti soggiorni di studio all’estero
If Yes, when? ...........................	
Se si, quando?
At which institution?......................................................................................
Presso quale istituzione?
I have benefited of Erasmus status before:                                    Yes         No  
Ho beneficiato dello status di studente Erasmus in precedenza:
	
	WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant)
ESPERIENZE DI  LAVORO (se rilevanti ai fini degli studi intrapresi)

Type of work experience               Company / organization                    dates                           country
Tipo di lavoro svolto                               Ditta / Ente                                           periodo                           paese
………………………………..         ……………………………………..     …………     ………………………
………………………………..         ……………………………………..     …………     ……………………….	
LANGUAGE COMPETENCE
              CONOSCENZA LINGUISTICA
D
I	            Livello di conoscenza
                       proficiency
Languages
Lingue straniere	
Mother tongue
Lingua madre	
Excellent
Ottima	
Good
Buona	
Fair
Media	
F	        Italiano	            	             	             	             	
I	        English	            	             	             	             	
R	        Français	            	             	             	             	
E	        Deutsch	            	             	             	             	
N	        Español	            	             	             	             	
Z	Other: .........................	            	             	             	             	
E	Other: .........................	            	             	             	             	
         Language of instruction at home institution (only if different from mother tongue) …………………………….
        Lingua di insegnamento nell’università di origine (solo se diversa dalla lingua madre) 

Information concerning the Italian Privacy Protection Law (Art. 13 of the Leg.Decree nr. 196 of June 30, 2003) 
The University of Florence will process the personal data provided in the present form exclusively for Erasmus –related procedures and in compliance with its institutional aims. 
Communication and diffusion of Personal Information
According  art. 11 of the Regulations for the implementation of the Personal Data Protection Code, I herewith authorize the University of Florence to process and communicate my personal data to the Public or Private Bodies which will request them, with the aim of implementing orientation, education, professional training  and employment opportunities, also abroad, for young students and graduates.
YES □  NO □
Date _______________________							Signature_____________________________