Period of study abroad:

Spring semester 201__ / Autumn semester 201__

Please indicate which semester(s) substitutes your study abroad:

Semester number ____ of ____ semesters

Please indicate period for your study abroad:

From: date ____ month ____ year ____

To: date ____ month ____ year ____

Faculty /School:

Programme of study:

Head of Programme / Department:

International contact person:

Sending institution:

Faculty /School:

Faculty of Health Sciences /

Programme of study:

Head of Programme / Department:

International contact person:

Receiving institution [change to your institution]:

Suite 7032, 43 Bedford Street, London, England, WC2E 9HA
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First name(s):

Last name(s):

Sex:

Male __ / Female __

Civ. Reg. No.
(date of birth):

Phone:

In home country:

While abroad:

Student No.:

Nationality:

Place of birth:

Permanent address in home country:

Current address abroad– valid until:

E-Mail at home institution:

Private E-mail:

Next of Kin Information:

Whom to contact if necessary.

Name:

Address:

Tel:

E-mail:

Institution

Country

Period of Study

From To

Duration of

stay

(months)

No. of expected ECTS

credits

1.

2.

Briefly state the reasons why you wish to study abroad:

Mother tongue: __________________

Language of instruction at home institution (if different): _________________

Language test results (attach certificate): Language test at: _________________
Score result: _______________

Other

languages

I am currently studying this language

I have sufficient

knowledge to follow lectures

I will have sufficient knowledge to follow lectures if I get some extra preparation

Yes

No

Yes

No

Yes

No

English

Danish

Number of higher education study years prior to departure abroad:

Have you already been studying abroad?

Yes: ___

No: ___

If yes, when?

At which institution?

Have you received a grant previously?

Yes:___

No:___

If yes which grant, when and for which activity?

The attached “Learning Agreement” includes full details of required courses and projects to attend during my intended study period at the Host University.

Please mark if you are interested in being contacted about residential facilities for students at VIA University College

Name of student:

Date:

_________________________________

Signature

Approved by Sending Institution:

Date:

_________________________________

Signature (Int. Contact Person)

We:__________________________________________________________________________

hereby acknowledge the receipt of the application and the student’s proposed Learning Agreement.

The above-mentioned student is:

accepted at our institution

not accepted at our institution

___

___

International contact person

Name:

E-mail:

Tel: +

Head of Programme

Name:

Date:

________________________________

Signature