FUND FOR COOPERATION & KNOWLEDGE III APPLICATION FORM

Al Magnifico Rettore Universit degli Studi di Pavia

Il/la sottoscritto/a NAME AND SURNAME chiede di partecipare alla selezione per lassegnazione di una borsa di studio, nellambito del Programma Fondo per la Cooperazione e la Conoscenza per lA.A. 2012-2013. (The undersigned NAME AND SURNAME asks to partecipate
to the selection to receive a scholarship, through the Programme Fund for Cooperation and Knowledge for the Academic Year 2012-2013).
1. Student Personal Information: (typewrite your data on this form in English) Family name: First name: Date of birth: d d / m m /1 9 - Place of birth (city): Sex (male/female): M Country of birth:

4. Attach here a passport size picture

Nationality: - select your country here - - - or here - - - or here - - - or here Marital status: single Children: No: 0 2. Address: Permanent postal address:

City: Telephone:

Country: Email: DD/MM /2012

3. Proposed arrival date at the University of Pavia: 5. References: Referee1: Title surname name phone fax email Name of the university of the referee:
1

Attach a recent letter of reference duly signed by your referee (a university professor). Reference sent directly to the University of Pavia will not be accepted.

6. Academic Background: I graduated Bachelor Degree in at the University name of the University Main subjects / Major: Level --Note: You must attach copy of the academic transcript of your previous university studies: a dichiarazione di valore in loco of your transcript (it is a document issued in Italian by the competent Italian diplomatic authority) will be required to selected candidates for finalizing the enrolment to the University of Pavia.

7. Proposed Course degree at the University of Pavia: Master in select a Master Degree 8. Language competence: Mother Tongue:
Other languages I am currently studying this language YES 1. English 2. 3. NO I have sufficient knowledge to follow lectures YES NO I would have sufficient knowledge to follow lectures if I had some extra preparation YES NO

9. Application form and attachments checklist:

Complete application form;

Motivation letter;

Transcript of records format); Recent medical certification;

Recent letter of reference;

Curriculum Vitae (European

Photocopy of passport/ ID.

10. I, the undersigned NAME SURNAME, confirm and guarantee that all the data and information

contained in this application form and in all the attachments are accurate and complete.

Date: DD / MM / 2012

Student Signature:

11. Application form and all attachments must be merged in one PDF file of Max. 5 MB and sent by email to: fund.cooperation@unipv.it

Deadline:

18 May 2012 12.00 p.m. (Italian time) late and incomplete applications will not
be considered