Mẫu số 01

Ban hành kèm theo Quyết định số /QĐ-ĐHKHCN

ngày tháng năm 20

APPLICATION FORM FOR OUTGOING EXCHANGE STUDENT

A. PERSONAL INFORMATION

Full Name : Nguyễn Văn Tài Student ID: BA10-055

Date of birth (DD/MM/YYYY):10/01/2001 Nationality: Vietnam

Address : 6/A32 Hoang Quoc Viet Street, Cau Giay Phone number: 0334 099 085
District, Ha Noi
Email : tainv.ba10-055@st.usth.edu.vn
Are you currently receiving a scholarship? ✔ No ☐ Yes
If yes, name of scholarship:

EMERGENCY CONTACT

Full Name: Nguyễn Văn Tuyển Relationship: Father

Address: Đan Que, Trung Chinh, Luong Tai, Bac Telephone/ Mobile:0366 769 537
Ninh

MEDICAL/ DISABILITY NEEDS

Do you have any physical or medical conditions? ✔ No ☐ Yes If yes, indicate the condition/s:

Do you need to take any special medication? ✔ No ☐ Yes

B. USTH COURSE DETAILS:

Intake: 2019 – 2023 Credits completed at time of application: 89

Major: ICT

Intended graduation Month/ Year: 07/2023 Credits left to complete your degree at time of application: 91

C. EXCHANGE DETAILS:

Preferred host institution: Alternative host institution (if apply for several exchange
programs):

Length of Program: ☐ Short Term Program ( _weeks) ☐ 1 Semester ✔ 2 Semester

Year of exchange: 2022 Semester of exchange: ✔ Spring semester ☐ Fall semester

Intended starting date of exchange: Intended ending date of exchange: 02/2023
09/2022

Finance for exchange: ☐ Self-funding ✔ Host institution ☐ Others, please specify:……………………

D. STATEMENT OF PURPOSE

Please provide a written Statement of Purpose (up to 500 words). Below are some suggestions for your
SOP:
• What kind of cultural differences do you expect to encounter during your proposed study abroad? How do
you plan to overcome them with your knowledge, experiences and gained skills at USTH?
• Focus on your chosen host institution. Why do you think that institution fits your expectations and
capability? How does the exchange program at that university contributes to your future plan and self-
development?
• What advantages and disadvantages do you see study exchange bringing to your life?
For applicants who apply for funding (Erasmus or other sources):
• Why do you think you are a good candidate for the scholarship? Give solid justifications that you are not
only a qualified student being able to follow the courses abroad, but also an appropriate ambassador for
USTH and Vietnam in the eyes of international friends.
In considering the above questions, try to draw on previous experience that you have had, whether it be a
cultural change you have experienced, a study or travel experience that has affected you, or knowledge that
you gained from others who have influenced you.

E. STUDENT DECLARATION

I declare that, to the best of my knowledge, all information on this form is complete and accurate.
I understand that the University may, with due regard to the University’s Regulations, obtain confirmation
of records from any institution attended by me and may provide information to Government bodies as
required by law. I also understand that the University reserves the right to vary any decision made on the
basis of incorrect or incomplete information supplied by me.
I understand that on becoming a student in this program I shall be subject to all the rules, regulations and
general code of practice for students enrolled at University of Science and Technology of Hanoi, the
participating institution, and overseas host residence in the International Exchange Program.
I also understand that I will be bound by the laws of the host country in which my exchange studies are
based.
Further, I declare that I have read the information in the Student Exchange Guide and attended an
Information Session, and am satisfied with the level of services and facilities as described, and agree to
abide by the Guidelines contained therein.
I have fulfilled all requirements of the checklist on page 1 of this application
I will provide a testimonial about my exchange experience to the International Cooperation Office upon my
return.
Signature of Applicant   

    Date: ____/____/20_____

OFFICE USE ONLY

EXCHANGE APPROVAL BY ACADEMIC DEPARTMENT

Enrolment at Host Institution Equivalent Enrolment at USTH

No. Course Name of Course ECTS No. Course Name of ECT Note
Code Code Course S
Machine
1 Data Mining Mod. 6 1 learning and 3
145547
Machine Learning Data mining I

2 140266 Computer Vision 6 2

Computer
3
Vision

Distributed systems Distributed

3 145617 6 3 3
1/ Distributed Systems
systems 2

Total 18 18

☐ Approved Name: ____________________________________

☐ Rejected Title: _____________________________________

Signature: _________________________________
☐ Need to consider/ Other comments
Date:______________________________________

Noted by ICO

CONTACT:
International Cooperation Office
Room 106, 1st Floor, A21 Building, University of Science and Technology of Hanoi
18 Hoang Quoc Viet, Cau Giay, Hanoi
Phone: +84 24 3791 8619 / Email: ico@usth.edu.vn