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Application form 2014

Only fully completed and signed applications can be accepted!

1. APPLICANTS PERSONAL DATA
Surname/Family name
(as indicated in your passport)
Forenames/Given names
(as indicated in your passport)
Date of birth (DD.MM.YY)
Place of birth
Gender

Female
Male

Identity card no. :

Expiry date:
Passport no. :
Expiry date:
Nationality

Native Language(s)
Family status
Current address
Street and number
Postcode
City
Country of residence

Permanent address (This address will be used to send all official documents in case of selection.
You must insert the complete information and the most adequate address. Any problem in sending
documents resulting from erroneous or insufficient information provided in this section and consequent
need to resend the documents will result on the payment, by the candidate, of the expenses associated to
this.)

Street and number

Postcode
City
Country

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Contact details
Telephone (with country
prefix):
Primary email:
Alternative email:

Additional information (By signing this application you declare you have not resided nor carried

out your main activity - studies, work, etc., for more than a total of 12 months over the past five years in
one of the European countries.)

How did you get to know the

project?
Have you applied at the same
time to other financial support
(Project funded by the
European Union or other)

Yes

No

Yes

No

If yes, please specify which

financial support.
Are you in a particularly
vulnerable socio-economic
situation?

Do you have any physical

disability?

If yes, please upload a formal document (dated, signed

and stamped by the issuing entity) that specifically
proves your vulnerable situation.
Yes

No

If yes, please upload a formal document (dated, signed

and stamped by the issuing entity) that specifically
proves your vulnerable situation.

Your mobility:

Please mark:
Applicant from Target Group 1 (Asian / Third country Partner
university)
Applicant from Target Group 2 (Associate institutions)
Applicant from Target Group 3 (Persons in vulnerable situations =
disabled or economically disadvantaged people or indigenous
population)
Application for (please choose only one option):
Undergraduates
5 months
or
10 months
36 months
Masters
5 months
or
10 months
24 months
Doctorates
10 months
or
36 months
Post Doctorates
6 months
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or
or

Academic Staf

1 month

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2. HOME INSTITUTION
Full name of your current Home Institution (university, company, research
centre, etc):
City
Country
Are you student:

Yes
Field of study
Name of the study program
Faculty/School
Department
Planned date of graduation
Name of the responsible person
Position of the responsible person
Email of the responsible person

No
Field of work
Description of your position

3. HOST INSTITUTION
Please choose max. 2 host universities from the list of Partner universities.
1st priority
Name of the institution:
Country
Field of study:
Duration of stay in months:
Start of the mobility (MM/YY):
End of the mobility (MM/YY):
Is your proposal part of any common project of
the two institutions?

Yes

No

Yes

No

If yes, please indicate the references.

Have you established any previous contacts

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with the Institution concerning your mobility?

If yes, please quote the name of the contacted
person.
Why have you chosen this type of mobility? (Max. 1000 characters)

Why have you chosen this specific institution? (Max. 1000 characters)

2nd priority
Name of the institution:
Country
Field of study:
Duration of stay in months:
Start of the mobility (MM/YY):
End of the mobility (MM/YY):
Is your proposal part of any common project of
the two institutions?

Yes

No

Yes

No

If yes, please indicate the references.

Have you established any previous contacts
with the Institution concerning your mobility?
If yes, please quote the name of the contacted
person.
Why have you chosen this type of mobility? (Max. 1000 characters)

www.alfabet-em.cz

Why have you chosen this specific institution? (Max. 1000 characters)

4. PREVIOUS EDUCATION
SECONDARY SCHOOL EDUCATION
Name of the institution:
City
Country

Exact Date of the Final

Examination (e.g. 12.06.2013)
Original name of examination
Please include a copy of your school leaving exam!
UNIVERSITY EDUCATIN (including study abroad) :
Full name of the institution delivering your previous degree(s) all the last degrees
completed:
Name of the institution:
City
Country
Study programme
Period of study (give months and
years)
Degree obtained
Result/Final grade
ADD THESE LINES ACCODING TO THE NUMBER OF DEGREES OBTAINED:
Name of the institution:
City
Country
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Study programme
Period of study (give months and
years)
Degree obtained
Result/Final grade

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5. FOREIGN LANGUAGE COMPETENCE

Languages

In this language I
can participate
actively in
scientific
discussions
without
difficulties
yes
no

I have
sufficient
knowledge to
follow lectures

I would have
sufficient knowledge
to follow lectures if I
had some extra
preparation

yes
no

yes
no

yes
no

yes
no

yes
no

yes
no

yes
no

yes
no

Language certificates (full name, date, score)

_________________________________________
_________________________________________
Please provide a copy of an English certificate required by the university of your
choice*!
Language tests, which will be taken before the scholarship
___________________________________
Date of test
___________________________________
* Visit the website www.alfabet-em.cz to check the English requirements for the
university of your choice.
6. WORK EXPERIENCE RELATED TO CURRENT STUDY
Type of work
experience /

Name of the Institution

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Period

Country

7. ONLY FOR STUDENTS (INCLUDING PHD): 2 RECOMMENDATION

LETTERS OF SENIOR ACADEMICS
Please add 2 recommendation letters in a closed envelope.
Title, Name of the
recommending
professor

Institution

Subject area of the

professors

I certify that the information in this application is accurate; failure in filling true data
can result in my exclusion from the project activities. I certify that I will tell personal
changes and additions immediately to the project coordinator Czech University of Life
Sciences Prague. I agree that this application and accompanying documents can be
forwarded to partner Institutions, who are cooperating in this programme.
_______________________________
Place and date

______________________________
Signature of the applicant

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CHECKLIST FOR ENCLOSURES TO BE ADDED:

Please provide English translations of all the documents!
1.CV
2.Motivation letter describing your motivation (1 page)
3.Academic transcript (an official list of courses you have attended so far,
including Grade Point Average)
4.Copy of your secondary school / high school leaving certificate or
university entrance exam results (only for Bachelor students)
5.Copy of your bachelors degree or an equivalent amount of ECTS credit
points (180) if you want to register for a Master programme
6.Copy of your Masters/ diploma degree if you want to register for a PhD
programme
7.Copy of an official English language certificate + other language certificates
(if any). Department of languages of the university can provide you relevant
document.
8.Copy of your passport (page with your picture) or personal ID card, if you do
not have a passport
(Candidates finally selected for mobility will be required to obtain an
international passport before being able to travel to Europe!)
9.One passport-sized photograph
10.Proof of registration (enrolment) at the university for exchange
students for short term mobilities
11.For BSc, MSc and PhD students: one recommendation letter (from academic
staff, employers or professional organization)
12.For PhD, Post-Doc and Academic Staf: maximum 3-page research proposal
including references (see the guidelines)
13.If applicable: proof of belonging to target group 3 (e.g. medical certificate or
confirmation of refugee status etc)
Other documents
After acceptance of your application, you may be requested to have ALL
TRANSLATED DOCUMENTS OFFICIALLY AUTHORISED (AND ALL DOCUMENTS
CERTIFIED by embassies/ministries as requested by your host university) and
to submit additional documents (e.g. medical certificates).

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