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UMAP standard application form and study plan using UCTS 1, 1. STUDENT'S PERSONAL DATA

(NOTE: To be completed by the student. The information provided in this form will be treated in confidence by the home and host institutions Data from the form may be used for UMAPIUCTS statistical purposes, but only in an aggregated and non-identifiable manner.)

Student's Name: (Gender: M I F) Student ID Number: University year:

Home Institution: Home Country: Degree & Major:

Host Institution: Host Country: Exchange Semester & Year:

Language Proficiency: (name of Language Test) (Level) Health Insurance:

2. DETAILS OF THE PROPOSED UMAP STUDY PLAN - 1 SEMESTER (from (mmlyy) to ( ~ ~ I Y Y ) (NOTE: To be completed and signed by the student and counter-signed by academic staff members of both institutions.)

1

Course number, Title and weekly T.H. (Teaching hours) and S.W.(Student's total workload, including T.H.) Credits

e HOST HOME .- , . . - . . . - &

Course # Title T.H (S.W) Course # * weeks Title T'H (S'W) Credit UCTS Credit UCTS

* weeks ___I---------

*NOTE: Number of instruction weeks for that academic semesterlterm, excluding both reading and examination week(s)

Note: If necessary, continue the list on a separate sheet, including any changes to the approved program, which must be signed and counter-signed.

Student's signature: Date:

We confirm that the proposed program o f study is approved.

I Home Institution's academic advisorlstaff member I Host University's academic advisor1 staff member

Signature:

Title:

Signature:

Title:

I Date: I Date: