FAC SIMILE. Year 2013/2014. Curriculum (high school diplomas) : inserire le informazioni sul proprio titolo di studio delle scuole superiori

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1 APPLICATION FORM FAC SIMILE Year 2013/2014 Stick photo here Double degree (INGE 11) S7 (XING12) S7+S8 (XING12) S8 (XING12) S9+S10+S11/ 3rdyear (XING13) État civil (compilare con le informazioni personali) Family Name First Name Second Name Date of birth / / City Country Nationality Gender F-Female M-Male Familial position 1-Single without child 2-Couple without child 3-Single with child 4-Couple with child Handicap A-Hearing AM-Spastic Hearing T-Hearing Spastic Visual AV-Hearing Visual M-Spastic MV-Spastic Visual V-Visual XX-Others Curriculum (high school diplomas) : inserire le informazioni sul proprio titolo di studio delle scuole superiori Year 0031-International high school degree 0001-International or European BAC French Baccalauréat Category Class P-Passed AB-Satisfactory B-Good TB-Very good Name of high school t Department Country Address (inserire il proprio indirizzo di residenza ATTUALE) Parental Address Zip code Country Phone Number Type of accommodation for the academic year 8-ECP Campus (Residence ECP 2, avenue Sully Prudhomme Châtenay-Malabry) room 5-Private accommodation 2-Approved Student Home 7-Other Specify your address if not on the campus Zip code Country Cell Phone Personal Person to contact in case of emergency in France Phone Number Cell Phone

2 Registration System 1-Initial Training 01-Student Student s job 82-No Professional Activity Father s job Mother s job l If you are registered as a higher level athlete, please specify National level Regional level University level International Exchange Program A- Students welcomed at Ecole Centrale Paris G-Double degree TIME program M-CAMBRIDGE Exchange Program P-Double degree outside TIME program Q-ERASMUS Exchange Program E-ARFITEC Exchange Program R-ERASMUS MUNDUS Exchange Program N-BRAFITEC Exchange Program F-MEXFITEC Exchange Program O-CHILFITEC Exchange Program Not specified University of origin Università degli Studi di Padova City Country Institution of higher education attended 10-International Date (year) inserire l anno accademico di immatricolazione ALLA TRIENNALE Name of the institution Università degli Studi di Padova Situation during 2012/2013 t Country P-Secondary or higher international institution Name of the institution Università degli Studi di Padova t Country Highest degree obtained (riguarda la scuola superiore frequentata) Date (year) 001-French Baccalauréat 500-International higher education degree 501-International High school degree Name of Institution t Country Are you registered elsewhere in your country? 10-International Name of university of origin Università degli Studi di Padova t Country Application Double Degree (INGE 11) S7 (XING12) S7+S8 (XING12) S8 (XING12) S9+S10+S11/ 3rdyear (XING13) Scholarship granted for this registration French Government Scholarship 66-CHILFITEC 64-ERASMUS 62-ARFITEC 50-CHINA SCHOLARSHIP COUNCIL 65-ERASMUS MUNDUS 61-BRAFITEC 30-EIFFEL 63-MEXFITEC No scholarship

3 Health Insurance Student health insurance is mandatory in France. You may take the French student health insurance (Sécurité Sociale) for a cost of 210 for any period during academic year You may decline this insurance if you have comparable coverage (i.e; with no upper limit) by your own insurance provider. In this case, please provide the name of the provider and the copy of your health insurance certificate. Private insurance European Health Insurance card (EHIC) French student health insurance ( 210 ) 601 LMDE / 617 SMEREP If you may take French student health insurance, please specify Father s Surname and Name Mother s Surname and Name Personal Liability Insurance Personal Liability Insurance (è l assicurazione di responsabilità civile, ma voi studenti avete già l assicurazione presso l università di Padova, quindi non vi serve) Do you have a Personal Liability Insurance? Yes No If not you will to subscribe to French Personal Liability Insurance (16 to 27 ) Proof of funds Students coming for one or two semesters, or two years should be able to inform us how they plan to finance their studies in France. They are therefore requested to submit proof of funds of * for the academic year. This can for example be a bank statement, or a scholarship/grant letter Certificate upon honor I the undersigned, certify that all information above is true. City, / / 20 Riguardo a questa parte relativa alla Health Insurance, dovete indicare il vostro tipo di assicurazione medica e consegnarne una copia cartacea al dott. Zorzi martedì 23 aprile. Se avete la normale tessera sanitaria italiana (TEAM), portate al dott. Zorzi una copia di quella e segnate la casella European Health Insurance card (EHIC). ATTENZIONE: se avete la tessera TEAM dovrete recarvi presso la vostra USSL prima della partenza per l estero, per eventuali informazioni sulle modalità di copertura sanitaria in FRANCIA. Normalmente, per la Francia l USSL vi fa compilare un modulo aggiuntivo, grazie al quale potrete farvi rimborsare le eventuali spese mediche sostenute, dopo essere rientrati in Italia dal vostro periodo di permanenza all estero.

4 Academic Background Number of semesters beyond High School completed at the intended date of arrival at Ecole Centrale Paris (indicare il n. totale di semestri c ompletati all università prima della partenza Highest degree obtained Date and Institution _(indicare il titolo di Scuola Superiore) Specialty Language level Please indicate your level of proficiency in French and English (at the time you are filling out this form) by checking the appropriate boxes below. French English - Native O O - C2 Excellent or nearly speaker O O You are able to put into practice all complex aspects of the work environment without any problems and can present them - C1 Very good knowledge O O You are able to create detailed presentations and reports - B2 Good knowledge O O You are able to edit and convey extensive information - B1 Relatively good knowledge O O You are able to process standard information of the work environment - A2 Basic knowledge O O You are able to understand and complete simple information and create short texts - A1 No or very little knowledge O O You are able to give, understand and complete information using simple linguistic structures If your level is below B1 now, please indicate how you plan to reach this level by the time classes start (language program, etc ) _(ad esempio: Self-Study and a Linguistic Course Given at my Home University ) Academic Advisor at the Home Institution Contact Name Prof. Pierfrancesco Brunello Position: Full Professor and T.I.M.E. coordinator Phone Number pierfrancesco.brunello@unipd.it Date / / 2013 Signature and official seal or stamp (non serve) Office of International Programs at the Home Institution Contact Name ZORZI MIRCO Position Erasmus agreements, T.I.M.E. Administrative contact Phone Number Fax mirco.zorzi@unipd.it Date / / 2013 Signature and official seal or stamp (non serve)

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