UNIVERSITY OF D ORTMUND

Summer School 2004

Application form

1) Personal Data

First Name: Last Name:

Academic Degree (if already finished):

Sex (please tick): female male Nationality:

Date of birth: Place of birth:

2) Mail addresses

Relevant address Home address

c/o
Street
Postal code/city
Country (incl. Postal letter)
Phone number
Email
3) Higher Education

Country Name of the university/ Duration Degree Grade

(Abbr) College, etc. from-till e.g. B.Sc include scale
If necessary

4) Knowledge of English

Are you a native speaker ? Yes! No!

If not, have you taken a TOEFL (or similar) test Yes! No!

If so, what score/ grade did you achieve?

Comments:

5) Knowledge of German/ Deutschkenntnisse

Are you a native (German) speaker Yes! No!

On a scale from 0(no German at all) -10(native speaker), how good is your German?

0 1 2 ✔ 3 4 5 6 7 8 9 10

Did you receive any certificate for that ?

In case, which one?
6) Reasons for the application

I assure that all de tai ls given in this applic at ion are correct and comple te. I know that
negligent or intentional misinformation may lead to my exclusion from admission or – if
discovered later – to the revocation of my admission or registration.
I will email this (filled in) form to Summer School@uni- dortmund.de as well as to send it
by conventional mail including my signature and all other relevant documents (e.g.
certificates, letters of recommendation, photograph, etc.)
In case of the admission, I will pay the handling fee of € 850 (incl. housing, public
transport, health insurance, etc.) immediately to the account given in the admission letter.

Location Date Signature