ERASMUS+ PROGRAMME

STUDENT APPLICATION FORM 2021/2022

POZNAN UNIVERSITY OF TECHNOLOGY (PUT) (Photograph)

FACULTY (at PUT): choose

___________________________________
from the list

This application should be completed electronically

SENDING INSTITUTION

University name: _________________________________________________________________

University address: _________________________________________________________________
Institutional coordinator: _________________________________________________________________
( name and surname / telephone / e-mail )

STUDENT’S PERSONAL DATA

First name: ________________________________ Surname: ___________________________________

Gender: F M Nationality: ________________
Date of birth: _____________________ (dd/mm/yyyy)
Place of birth: ______________________________
Country of birth: ____________________________
E-mail: ___________________________________
ID number: __________________________________
Passport numer: ______________________________
Father’s name: _______________________________
Mother’s name: _______________________________
Permanent address: ___________________________
(postal code city)

Tel.: _____________________________________ ____________________________________________

INFORMATION ABOUT STUDIES

Diploma/degree for which you are currenly studying at home institution: choose from the list

Programme which you are going to study at PUT: choose from the list

Period of stay at PUT : from _____________ (dd/mm/yyyy) to _____________ (dd/mm/yyyy)

Semester at PUT: __________________

winter semester

Will you take part in the Orientation week before the beginning of the semester? Yes ✔ No

Would you like to book a place in PUT dormitory? Yes No

Signature of the student ………...................... Date______________