ISA Lille. Head of International Relations Office: Ms Florence MALAISE. This form must be filled in completely. Type or write very clearly (in black ink).

ISA Lille

48 Boulevard Vauban

59014 LILLE cedex - FRANCE

Head of International Relations Office: Ms Florence MALAISE

+33 (0)3 28 38 46 10

Isa. international@yncrea. fr

oSemester 1 (Fall)

oSemester 2 (Spring)

oSemesters 1 & 2 (one academic year)

oDouble degree

Expected arrival date: …………………………………….

Expected departure date: ………………………………..

Application deadline: April 30^th

Application deadline: October 31^st

Application deadline: April 30^th

Application deadline: April 30^th

Number of years of study prior to departure:

Date of birth (D, M, Y):

Place of birth:

Last name:

First name:

Gender:   Female 􀂅

                 Male 􀂅

Nationality:

Mother tongue:

Current address:

: ………………………………………………………………………………………………

City: ………………………………………………………………. …

Postal code: ………………………...

Current address

is valid until:

Tel:

Fax:

E-Mail:

Home University:

(Full name)

Erasmus code for

European Universities:

Contact person at home University:

(name, address, tel, fax, e. mail)

Excellent o

Excellent o

Excellent o

Excellent o

Excellent o

Excellent o

Advanced o

Advanced o

Advanced o

Advanced o

Advanced o

Advanced o

Type of Exchange Programme:

oERASMUS

oOther (please specify):

oBilateral institutional agreement

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