Annex 2 Erasmus+ for Traineeship a.y. 2017/18
(IT IS MANDATORY TO FILL-IN DIGITALLY AND ATTACH THIS FORM TO THE ON-LINE APPLICATION FORM)
	
I certify that all the information reported on this form is complete and correct.

I, hereby undersigned: Matriculation number __________ Family name ________________________ name __________________________
declares the following:
□ to be officially enrolled for the year 2017/2018 
□ to be a student who is graduating within the extraordinary sessions of academic year 2016/2017 and starting the planned traineeship period after graduation.
□  to be a student of the structured mobility programmes who is graduating within the extraordinary sessions of academic year 2016/2017 and planning the traineeship period before graduation.
□  to be a student who is graduating within the extraordinary sessions of academic year 2016/2017 and who for the academic year 2017/2018 will be officially enrolled in:
•	Master’s degree in Economics and Public Policies
•	Master’s degree in Chemical Sciences
•	Master’s degree in Science and Geological Technologies
•	Master’s degree in Engineering for environmental sustainability
•	Master’s degree in Materials Engineering
•	Master’s degree in Industrial Biotechnologies
•	Master’s degree in Medical Biotechnologies
•	Master’s degree in Information Technology
•	Bachelor’s degree in Occupational Therapy
•	……………………………………………….
□ to have already received a previous grant for Erasmus Study and/or Placement and/or Traineeship offered by:
□ UNIMORE or □ University of________________________________________    for a total of _____________               months during the a.y.  ________________________
□ do not have received a previous grant for Erasmus Study and/or Placement and/or Traineeship
□ to have passed the following exams but they’ve not yet been registered:

N°	Date of the exam	Exam/other activity	Mark	      Credits	
1		 	 	 	
2		 	 	 	
3		 	 	 	
4		 	 	 	
5		 	 	 	

□ to have achieved the First Level Degree in _____________________________________ at the University of ______________________________ obtaining the following final mark___________ __ and to have passed the following exams:
N°	Date of the exam	Exam/other activity	Mark	semester/Credits	
1		 	 	 	
2		 	 	 	
3		 	 	 	
4		 	 	 	
5		 	 	 	
6		 	 	 	
7		 	 	 	
8		 	 	 	
9		 	 	 	
10		 	 	 	
11		 	 	 	
12		 	 	 	
13		 	 	 	
14		 	 	 	
15		 	 	 	
16		 	 	 	
17		 	 	 	
18		 	 	 	
19		 	 	 	
20		 	 	 	

LANGUAGE  KNOWLEDGES

IMPORTANT: Candidates shall state their knowledge of a common language (English, French, Spanish and German) not lower than the B2 level (Europass Language Passport). If the level of language knowledge stated in the application is lower than B2, students shall commit to reach the required level before they leave for the traineeship period.
Before they leave, students who are awarded the grant shall take a free language test on the OLS (Online Linguistic Support) European portal. 

ENGLISH:
-	any:  □
-	exam (mark) : _________ and/or passed NO □ – YES □ 
-	certificates : NO □ – YES □ (if yes it is mandatory to attach the certificate)
-	previous study experience(s) abroad: NO □ – YES □ (if yes, please specify where)
_______________________________________________________________________
-	previous assessment of language knowledges in order to enroll to the Master Degree: 
NO □ – YES □
-	other (please specify for ex. Mother tongue, etc.. ): __________________________ 	

FRENCH
-	any:  □
-	exam (mark) : _________ (and/or passed) NO □ – YES □ 
-	certificates : NO □ – YES □ (if yes it is mandatory to attach the certificate)
-	previous study experience(s) abroad: NO □ – YES □ (if yes, please specify where)
_______________________________________________________________________
-	previous assessment of language knowledges in order to enroll to the Master Degree: 
NO □ – YES □
-	other (please specify for ex. Mother tongue ): __________________________ 

GERMAN
-	any:  □
-	exam (mark) : _________ (and/or passed) NO □ – YES □ 
-	certificates : NO □ – YES □ (if yes it is mandatory to attach the certificate)
-	previous study experience(s) abroad: NO □ – YES □ (if yes, please specify where)
_______________________________________________________________________
-	previous assessment of language knowledges in order to enroll to the Master Degree: NO □  YES □
-	other (please specify -for ex.- Mother tongue ): __________________________ 

SPANISH
-	any:  □
-	exam (mark) : _________ (and/or passed) NO □ – YES □ 
-	certificates : NO □ – YES □ (if yes it is mandatory to attach the certificate)
-	previous study experience(s) abroad: NO □ – YES □ (if yes, please specify where)
_______________________________________________________________________
-	previous assessment of language knowledges in order to enroll to the Master Degree: NO □ – YES □
-	other (please specify -for ex.- Mother tongue ): __________________________ 
-		

PORTUGUESE
-	any:  □
-	exam (mark) : _________ (and/or passed) NO □ – YES □ 
-	certificates : NO □ – YES □ (if yes it is mandatory to attach the certificate)
-	previous study experience(s) abroad: NO □ – YES □ (if yes, please specify where)
_______________________________________________________________________
-	previous assessment of language knowledges in order to enroll to the Master Degree:  NO □ – YES □
-	other (please specify -for ex.- Mother tongue ): __________________________