Student application form - ANSG w Ostrowcu Świętokrzyskim

1. Full Name (as in passport/ID)

2. Gender

Male
Female
Other

3. Date of Birth

4. Nationality

5. Country of Permanent Residence

6. Email Address

7. Phone Number (with country code)

8. Current Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

9. Name of Home University

10. Faculty / Department

11. Field of Study

12. Level of Study

13. Year of Study

14. Erasmus+ Institutional Coordinator (name & telephone number & email)

Phone

E-mail

15. Type of Mobility

16. Planned Start Date of Traineeship

17. Planned End Date of Traineeship

19. Motivation Letter (Why do you want to undertake a traineeship at our institution?)

of at of

20. Expected Learning Outcomes (knowledge, skills, competences)

21. Native language

22. Language of Instruction / Work at Host Institution

24. Knowledge of Polish (if any)

None
Basic
Intermediate
Advanced

25. Special Needs / Accessibility Requirements (optional)

26. Accommodation Support

I expect assistance in finding affordable accommodation during my traineeship.
I do not expect assistance in finding affordable accommodation during my traineeship.

27. Dietary Preferences (select all that apply)

No special preferences
Vegetarian
Vegan
Halal

28. Do you drink alcohol ?

yes/occasionaly
no

Declarations

29. Declaration of the Accuracy of Information Provided
30. Consent to the Processing of Personal Data (GDPR compliance)
31. Confirmation of Familiarity with Erasmus+ Rules and Host Institution Regulations

After completing the form, please immediately send the remaining documents directly to the Head of International Relations Office at the following email address: international@goluchowski.edu.pl

a scan of your passport or ID card
medical insurance
a medical certificate stating that there are no contraindications to participating in the student internship
current certificate from the National Criminal Register in accordance with the Act on Counteracting the Risk of Sexual Offenses and Protecting Minors (from Poland and countries where the participant has lived in the last 20 years)
certificate of civil liability and accident insurance

SMT - STUDENT: Erasmus+ SMT form

POBIERZ
SMT - STUDENT: Erasmus+ SMT form
SMT- Erasmus+LA Student Mobility for Traineeships

POBIERZ
SMT- Erasmus+LA Student Mobility for Traineeships

Documents for download