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Country of origin: FRANCE
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Université de La Rochelle
Direction Relations Internationales
23 avenue Albert Einstein – BP 33060 – 17031 La Rochelle –
Tél : +33 (0)5 46 45 91 14 – Fax : + 33 5 46 44 93 76 – Email : dri@univ-lr.fr
actuelle :
Please return this form typewritten and signed to:
Please fill out the grey fields by typewriting. You can move to the next field with the TABKEY
Academic year/ année universitaire :
Field of study/ domaine d’études :
Current year of study / année d’études
STUDENT’S DATA/ Identité de l’étudiant
Family name/ nom:
First name / prénom :
Permanent address/ adresse permanente :
Date of birth/
date d
e naissance :
Place of Birth/ lieu de naissance :
Gender/ sexe: M F
Nationality/ nationalité :
Tel.:
e-mail :
LANGUAGE COMPETENCE/ Niveau de langues
Mother tongue/ langue maternelle :
Language of instruction at home institution (if different) :
French level / Niveau de
français
A1
A2
B1
B2
C1
C2
PREVIOUS STUDY/ Études antérieures
STUDENT APPLICATION FORM
DOSSIER DE CANDIDATURE ÉTUDIANT
Student identity
Name/ nom :
First name / prénom :
Home institution / :
université d’origine
Name and full address/ nom et adresse :
Institutional coordinator’s name / coordonnateur institutionnel :
Telephone : e-mail :
Period of study at the University of La Rochelle / Période d’étude à l’Université de La Rochelle :
1
st
Semester (September to January) 2
nd
Semester (January to June)
Academic Year (September to June One Year (January to December)
Last diploma obtained/ Dernier diplôme obtenu :
Year of graduation/ Année d'obtention :
Town of your high school/ Ville de votre lycée :
Université de La Rochelle
Direction Relations internationales
23 avenue A. Einstein
17031 La Rochelle Cedex 9 – FRANCE
Tel. : + 33 5 46 45 87 47
Fax : + 33 5 46 44 93 76
dri@univ-lr.fr
Université de La Rochelle
Direction Relations Internationales
23 avenue Albert Einstein – BP 33060 – 17031 La Rochelle –
Tél : +33 (0)5 46 45 91 14 – Fax : + 33 5 46 44 93 76 – Email : dri@univ-lr.fr
RECEIVING INSTITUTION/
Etablissement d’accueil
Course/ code & title Cours/
code et intitulé
ECTS Credits
Crédits ECTS
Etablissement d’origine
corresponding course at home institution
(code & title)
Cours correspondants dans l’université
Cours de français gratuits au CUFLE (6 ECTS)
If necessary, please use a separate sheet/ si nécessaire, merci d’utiliser une feuille séparée
SENDING INSTITUTION / ETABLISSEMENT D’ORIGINE
We confirm that this application is approved/ Nous confirmons que ce contrat d’études est approuvé
Name of departmental
coordinator
coordonnateur de
département/UFR :
Date:
Signature :
Name of Programmes advisor
responsable de la formation :
Date:
Signature :
Name of institutional coordinator
coordonnateur institutionnel :
Date:
Signature :
Stamp/ cachet de l’établissement
RECEIVING INSTITUTION/ ETABLISSEMENT D’ACCUEIL
We confirm that this application is / Nous confirmons que ce contrat d’études est approuvé
Name of departmental coordinator
Name of Programmes advisor
Name of institutional coordinator
coordonnateur institutionnel :
Stéphane Aymard
Date:
Signature :
Stamp/ cachet de l’établissement
responsable de la formation :
coordonnateur de
département/UFR :
Date:
Signature :
Date:
Signature :
STUDENT APPLICATION FORM
DOSSIER DE CANDIDATURE ÉTUDIANT
Student identity
Name/ nom :
First name / prénom :
Home institution / :
université d’origine
Date:
Student’s signature :
signature de l’étudiant
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Completed 26 October 2020

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