Université Lille 1

Exchange students - Application form

 

 

 

 1. SENDING INSTITUTION (To be completed by the Coordinator in your home institution)

 

Name of the institution
Country
Socrates identification code(If  applicable)
Name of co-ordinator in home   institution
Faculty / department
Email	@

 

 

 2. PERSONAL INFORMATION

 

Surname
Forenames
Sex
Date of birth (day/month/year)	/                       /
Country of birth
Nationality
Permanent home address
Email address	@
Address for correspondence
Valid until

 

 

 3. STAY IN LILLE

 

Faculty / Department of studies
Departmental co-ordinator
Period of study	from :        /         /   to :           /         /
French language   proficiency(Please tick)	poor       average       good       fluent
Registration to the French   language course(Please tick)	yes       no

                 Student’s signature :                                                         Date :        /         /

 

                 Home co-ordinator’s signature :                                         Date :        /         /

 

 

To be returned not later than 15 June for the first term
and 15 November for the second term to :

Mrs Delphine HIMPENS
Université des Sciences et Technologies de Lille
Cellule des Relations internationales – Bâtiment A3
F - 59655 Villeneuve d'Ascq
delphine.himpens@univ-lille1.fr
Fax : + 33 3 20 43 40 03