ECTS European Community

Course Credit Transfer System

Photograph

Student Application Form

Academic Year 200__/200__
Field of Study: Medicine
This application should be completed in BLACK in order to be easily copied and/or telefaxed.

SENDING INSTITUTION
Name:......................................................................................................................................................
City/Country: ...........................................................................................................................................
Period of study:

from.................................................to ...................................................................

Duration of stay (months) ................................................

RECEIVING INSTITUTION
Charit Universittsmedizin Berlin, Joint Institution of Humboldt-Universitt (D BERLIN13) and Freie
Universitt Berlin (D BERLIN 01)
Contact

Ms. Angelika Cernitori, Charit International Cooperation

Charitplatz 1, Virchowweg 24 - D-10117 Berlin
phone: ++49-30-450-576002
fax:
++49-30-450-576900
angelika.cernitori@charite.de

STUDENTS PERSONAL DATA

(to be completed by the student applying)

Family name: .......................................................

First name(s):.....................................................

Date of birth: ........................................................

female
Sex: ................
Nationality: ................................

Place of birth: .......................................................

Current address:

Permanent address (if different):

.............................................................................

...........................................................................

.............................................................................

...........................................................................

Phone:..................................................................

Phone.................................................................

E-mail:..................................................................

E-Mail:................................................................

ECTS Student Application Form page 1

Name of student: ....................................................................................................................................

Sending institution: .................................................................................................................................
LANGUAGE COMPETENCE
Mother tongue: .......................... Language of instruction at home institution (if different): ................
Other languages

I am currently studying
this language

I have sufficient knowledge

to follow lectures

Yes

No

Yes

No

o
o
o

o
o
o

o
o
o

o
o
o

...German..........
...........................
...........................

I would have sufficient knowledge

to follow lectures if I had some
extra preparation

Yes

o
o
o

No

o
o
o

German language test taken on _______________ Score: _________

PREVIOUS AND CURRENT STUDY
Diploma/degree for which you are currently studying:...Medicine.........................................................
Number of higher education study years prior to departure abroad: .....................................................
Have you already been studying abroad?

Yes

No

If yes, when? at which institution?..........................................................................................................

RECEIVING INSTITUTION
We hereby acknowledge receipt of the application and the proposed learning agreement.
The above-mentioned student is
Coordinators signature

o
o

provisionally accepted at our institution

not accepted at our institution
Stamp/Seal

..........................................................
Date:..................................................

ECTS Student Application Form page 2

ECTS European Community Course Credit Transfer System

LEARNING AGREEMENT
Academic Year 200__/200__
Field of Study: Medicine
Name of student: ....................................................................................................................................
Sending institution: ................................................................................................................................
DETAILS OF THE PROPOSED STUDY PROGRAMME ABROAD / LEARNING AGREEMENT
Receiving institution:

Charit Universittsmedizin Berlin

Course code and page

no. of the Information
Package

Number of
ECTS credits

Course title

According to attached "Course Application Form"

Students signature
..........................................................

Date: ......................................................

SENDING INSTITUTION
We confirm that this proposed programme of study/learning agreement is approved.
Coordinators signature

Stamp/Seal

..........................................................
Date:..................................................
RECEIVING INSTITUTION
We confirm that this proposed programme of study/learning agreement is approved.
Coordinators signature

Stamp/Seal

..........................................................
Date:..................................................

ECTS Learning Agreement page 1

Name of student: ....................................................................................................................................

Sending institution: ................................................................................................................................
CHANGES TO ORIGINAL PROPOSED STUDY PROGRAMME/LEARNING AGREEMENT
(to be filled in ONLY if appropriate)
Course code and page
no. of the Information
Package (if applicable)

Course title

Deleted
course

Added
course

o
o
o
o
o
o
o

o
o
o
o
o
o
o

Number of
ECTS credits
(if applicable)

Students signature
..........................................................

Date: ......................................................

SENDING INSTITUTION
We confirm that the above-listed changes to the initially agreed programme of study/learning
agreement are approved.
Coordinators signature

Stamp/Seal

..........................................................
Date:..................................................
RECEIVING INSTITUTION
We confirm that the above-listed changes to the initially agreed programme of study/learning
agreement are approved.
Coordinators signature

Stamp/Seal

..........................................................
Date:..................................................

ECTS Learning Agreement page 2