Application: Erasmus+ International Credit Mobility Exchange Student Scholarship @ Karlstad University, Sweden

Outbound International student exchange: Erasmus+ Student Mobility @Karlstad University, Sweden
Section A: Application details
Full Name*

First NameMiddle NameLast Name
RSU student ID number
Major Field study*
Faculty
Year of study*
Current grade point average*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Facebook (if any)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Date
Gender*
Country of Citizenship*
Passport number
Scan of Student Card*

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Section B: Exchange program details

At Karlstad University
Proposed field of study (Program, Faculty)
Purposed study plan
Please describe your motivations to participate in exchange program (No entry limit)*
Please describe why you should be nominated as the exchange student
Interests / Hobbies
Is English your first language?

If "No" please provide information on your English language proficiency*

	Very good	Good	Fair	Poor
Speaking
Listening
Reading
Writing

English language proficiency test score (if available)
Transcript / Study record*

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Upload scan of original transcript / study record issued by Registrar office of the home institution Cancelof
English language proficiency certificate

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Upload scan of original of English language proficiency score Cancelof

Section C: Emergency contact
Full Name of emergency contact person*

PrefixFirst NameMiddle NameLast Name
Relationship*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Section D: Reference
Name of Referee*

PrefixFirst NameMiddle NameLast Name
Title
Faculty / Office
Email
example@example.com
Phone number
Reference form

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Please upload reference form signed by reference Cancelof
Section E: Medical and further information
E1: Any disabilities and/or medical condition that RSU should be aware of?

YesNo
If "Yes" (E1), please explain
Disabilities and/or medical condition / Allergies list
E2: Have you ever been convicted of a criminal crime offense?

YesNo
If "Yes" (E2), please explain
E3: Do you foresee any other difficulty that may affect the completion of your exchange period?

YesNo
If "Yes" (E3), please explain
CHECKLIST

Have you uploaded the scanned of the following documents;
- scan of student ID card
- scan of transcript / study record
**This application will not be processed unless it is complete and is accompanied by the above listed documents.
APPLICANTS DECLARATION

By submitting this online Exchange application form, I certify that the statement made by me are true, complete, and correct to the best of my knowledge. I fully understand if I am to join the program, I agree to;
1. follow the course of study and abide by the rules of Rangsit University and the law of Thailand;
2. act in such a manner that I will not bring disrepute to myself, Rangsit University; host institution or my country of citizenship during the Exchange program;
3. abide by the rules and regulations governing my visa;
4. release information contained in this application form to relevant authorities and for RSU exchange student yearbook/semester book publication;
5. responsible for any study materials, personal and medical expense that shall incur during my exchange period at Rangsit University;
6. obtain full international travel and health insurance prior to the departure to Thailand;
7. the use of photographs of myself taken by Rangsit University - the likely uses include promotional materials, brochures, displays, expos, poster, cards, newspaper article, website, communication with educational agents and advertising.
8. the terms and agreements as per the Memorandum of understanding established in regard to exchange activity between the host institution and Rangsit University
Date

MonthDayYearHourMinutesAM/PM Option
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