Impreso de Solicitud / Application Form
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1 Fotografía/ Photograph Impreso de Solicitud / Application Form Sistema Europeo de Transferencia de Créditos / European Credit Transfer System Datos del estudiante / Student s personal data Apellido 1 / Family Name Apellido 2 / Family Name Nombre (s) / First name (s) Curso Académico / Academic Year / Fecha nacimiento / Date of Birth D.N.I. - Pasaporte / ID Card - Passport Nacionalidad / Citizenship Lugar de nacimiento / Place of Birth Sexo / Sex M/F Estado Civil / Civil State Dirección Actual / Current Address Válida hasta / Valid until / / Teléfono (Incluyendo prefijos) / Telephone (Including international codes): Universidad de Origen / Sending Intitution Nombre y Dirección completos / Name and full address Datos Académicos / Academic Data Dirección Permanente / Permanent Address (Si difiere / if different) Persona de Contacto en caso de urgencia / Contact person in case of emergency Dirección y Teléfono si difiere del anterior Address and Telephone if different from above Coordinador de área ( Nombre, teléf., fax, ) / Departmental Coordinator (Name, teléf., fax, ) Coordinador Institucional ( Nombre, teléf., fax, ) / Institutional Coordinator (Name, teléf., fax, ) Facultad / Instituto / Faculty / School Curso Actual / Current year Periodo de Estancia / Duration of stay Fecha de Llegada / Date of Arrival Fecha de Salida / Date of Departure Fecha / Date
2 Compromiso de Reconocimiento Académico / Learning Agreement Programas de Mobilidad de Estudiantes/ Student Mobility Programmes Sistema Europeo de Transferencia de Créditos / European Credit Transfer System Datos del estudiante / Student s personal data Apellido 1 / Family Name Apellido 2 / Family Name Nombre (s) / First name (s) Total créditos / Total credits Curso Académico / Academic Year / D.N.I. - Pasaporte / ID Card - Passport Ref. Programa de Intercambio / Ref. Exchange Programme Universidad de Destino / Host Institution... Código / Code Denominación / Course title Periodo / Period Institución de Origen / Sending Institution Créditos / ECTS Credits Institutión de Acogida / Receiving Institution
3 NUMBER OF E.C.T.S. DELETED COURSE UNIT CODE ADDED COURSE UNITCODE (IF ANY) AND PAGE N OF THE INFORMATION PACK. COURSE UNIT TITLE AND EQUIVALENT AT THE UNIVERSIDAD PONTIFICIA (AS INDICATED IN THE INFORMATION PACKAGE) DELETED COURSE UNIT ADDED- COURSE UNIT Total E.C.T.S. credits Institución de Origen / Sending Institution Institutión de Acogida / Receiving Institution SERVICIO DE RELACIONES INTERNACIONALES UNIVERSIDAD PONTIFICIA Compañia, SALAMANCA ESPAÑA Teléf Fax relint@ upsa.es
4 Conocimientos Lingüísticos / Language Skills Lengua Materna / Mother Tongue Conocimiento de Otras Lenguas / Language skills Nivel / Level Inicial / Beginner Medio / Intermediate Avanzado / Advanced Español / Spanish Inglés / English Francés / French Alemán / German Sólo para estudiantes que vengan a la Universidad Pontificia de Salamanca/Only for students coming to the Pontifical University of Salamanca Curso de Español / Spanish Course Está interesado/a en seguir el curso de español para estudiantes de intercambio / Are you interested in following the Spanish course for exchange students? SI / YES Alojamiento / Accommodation NO If YES, please send us the Spanish Language Course Registration form Quiere que le reservemos su alojamiento / Do you wish us to book accommodation? SI / YES NO If YES, please send us the accommodation form Explica brevemente las razones por las que has elegido la Universidad Pontificia de Salamanca para realizar tu período de intercambio / Give brief details of your reasons for studying at the Pontifical University of Salamanca.
5 Documentación / Documents Documentación para estudiantes de Salamanca / Documents for students from Salamanca No escriba en este recuadro / Do not write inside this box Contrato de estudios / Learning Agreement Certificado de ser alumno de intercambio / Exchange student certificate from the sending institution Certificación académica personal / Transcript of records Fotocopia de carnet de identidad o pasaporte en regla / Photocopy of valid passport or ID card Formulario E-111 (Seguridad Social) o de Seguro Privado / E-111Insurance form / Proof private insurance form Documentación para estudiantes que vienen a Salamanca / Documents for students coming to Salamanca Contrato de Estudios / Learning Agreement Certificado de ser alumno de Intercambio / Exchange student certificate from the sending institution Certificación académica personal / Transcript of records Fotocopia de carnet de Identidad o pasaporte en regla / Photocopy of valid ID card or Passport Formulario E-111 (Seguridad Social) o de Seguro Privado / E-111Insurance form / Proof private insurance form 2 Fotocopias tamaño carnet / 2 passport photographs SERVICIO DE RELACIONES INTERNACIONALES UNIVERSIDAD PONTIFICIA Compañia, SALAMANCA ESPAÑA Teléf Fax upsa.es
FORMULARIO DE INSCRIPCIÓN
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