STUDENT APPLICATION FORM EXCHANGE STUDENTS

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STUDENT’S PERSONAL DATA
(to be completed by the student applying, data should be conform information in passport)
Family name (for married woman maiden First name(s): Francesco
name): Di Giacomo
Marital status: unmarried married
Date of birth: 21 /4 /20
1987
Sex: Male Female Nationality: Italian
Place of birth: Rome (RM)
Country of birth: Italy

Current address: Permanent address (if different):

Via S. Angela Merici 96
00162 - Roma
Italia

Tel: 00393336882814 Tel:

Fax: Fax:
E-mail: digiacomo.francesco@gmail.com E-mail:

SENDING INSTITUTION (HOME UNIVERSITY)

Name and full address:
Università degli Studi di Roma "Tor Vergata"
Via Orazio Raimondo, 18
00173 - Roma
Italia
Departmental coordinator
Name:
Telephone:
Fax:
E-mail:

Institutional coordinator
Name:
Telephone:
Fax:
E-mail:

PREVIOUS AND CURRENT STUDY

Diploma/degree for which you are currently studying:

Master Degree in Science and Technology of Materials
Current field of study:

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Number of higher education study years prior to departure abroad: 4

Have you already been studying abroad? Yes No

If Yes, when? At which institution?

The attached Transcript of records includes full details of previous and current higher
education study. Details not known at the time of application will be provided at a later
stage.

RECEIVING INSTITUTION

PREFERRED FIELD OF STUDY AT TUE: Chemical Engineering and Chemistry

Period of study N° of expected

ECTS credits
✔ Semester A: 30 Aug 2010 - 28 Jan 2011
31
Semester B: 31 Jan 2011 - 1 Jul 2011

Preferred type of study during stay at TU/e:

✔ Courses
✔ Research project, please specify in which research area: Polymers technology
Final project/thesis project, please specify in which research area:
Internship, please specify in which research area:

Briefly state the reasons why you wish to study abroad?

To improve my knowledge of polymers and have the chance to use advanced laboratory.
This experience will also provide me the possibility to live abroad and improve my english.

NATURE OF VISIT AND GRANT

What is the nature of your visit?
✔ Erasmus study (courses, traineeship, at the university, on the basis of a bilateral agreement)
Erasmus student placements (in a company)
Erasmus Mundus External Cooperation Window
Within the scheme of another (non-Erasmus) bilateral agreement between TU/e and your
institution
Free mover
Other, please specify:
 LANGUAGE COMPETENCE
Mother tongue:
Italian
Language of instruction at home institution (if different):

I have sufficient knowledge to follow lectures in: Yes No

English
(Dutch)

Please give a proof of your sufficient knowledge of the English language in one of the
following ways:
An original
- An -original Academic Academic
IELTS IELTS
score of at score
least 6.5 of at least 6.0 on average
on average
- TOEFL
- scores of at least
TOEFL 90 (internet-based)
scores of at least 80 (internet-based), 213 (computer-based) or 550
- Statement of(paper-based)
your home institution (please use annex II)
- Statement of your home institution (please use annex II)

WORK EXPERIENCE RELATED TO CURRENT STUDY (if relevant)

Type of work experience Firm/organisation Dates Country
Stage at C.N.R. where I study the I.S.M. (Matter's structure 15/10/2009 Italy
amplification of chirality in 2D Institute) at C.N.R. 15/01/2010

Please enclose:
- copy of passport
- one passport photo (3 x 4 cm.)
- transcript of records of previous and current higher education
- learning agreement with proposed study program (if already known)
- proof of sufficient mastery of the English language

Please return this form to:

Technische Universiteit Eindhoven

Department of Chemical Engineering and Chemistry
Dr. Kim Pauwels
Room: STW 2.41
PO Box 513
5600 MB Eindhoven
The Netherlands

k.f.d.pauwels@tue.nl
DECLARATION AND SIGNATURES

SENDING INSTITUTION
Coordinator’s Name: Date:

Coordinator’s signature: Stamp institution:

RECEIVING INSTITUTION: TU/e

(to be completed by TU/e Department of Chemical Engineering and Chemistry )
We hereby acknowledge receipt of the application, the candidate’s transcript of records and the
learning agreement.
The above-mentioned student is
Accepted at our institution
Not accepted at our institution

Departmental coordinator’s signature:

Date:

Supervisor TU/e: _________________________________________________________

Bachelor’s/Master’s program: _______________________________________________

Period of study at TU/e: ____________________________________________________

Annex I
Application form for Services (compulsory)
Family name (for married woman maiden name): Di Giacomo

First name(s): Francesco

Date of birth:21 /4 / 1987 Place of birth: Rome (RM)

Email: digiacomo.francesco@gmail.com

Country of birth: Italy Nationality: Italian

Sex: male female

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Wishes to apply for:

ACCOMMODATION (please answer the following questions)

Accommodation period for: ✔ Semester 1 (9 Aug 2010 - 28 Jan 2011)

Semester 2 (28 Jan 2011 - 22 Jul 2011)

Please note that the above mentioned period is the period of the rental agreement of the accommodation. This period may differ from
the academic semester dates.
The costs for accommodation are approx. 2000 to 2500 euro for one semester.

Special remarks:

1
VISA (please answer the following questions):
Do you have a Dutch residence permit: Yes No
(If you choose “no” and you need a VISA the TU/e will apply for it)
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Insurance (please answer the following questions)
2
Do you have health insurance? Yes No
Do you have liability insurance? Yes No

If you do not have insurance you need to contact the International Relations Office on arrival. We can
arrange insurance for you with AON (www.students-insurance.eu)

Undersigned by:

Student Coordinator

1
If you come to the Netherlands as an exchange student for more than 3 months you might need an MVV (visa) to enter the Netherlands.
Students with the nationality of one of the following countries do not need to apply for a visa to enter the Netherlands: One of the countries
of the European Union, Iceland, Norway, Liechtenstein, Switzerland, Monaco, Australia, New Zealand, Canada, the United States of
America and Japan.
2
The Netherlands has signed treaties regarding health insurance with the following countries: all of the EU member states, Norway, Iceland,
Liechtenstein, Turkey, Morocco, most of the countries of former Yugoslavia, Tunisia, Cape Verde Islands and Australia. If you are insured
under the national health insurance scheme of one of these countries, your insurance company can provide you with an international
declaration form called E-111 or E-128. Make sure to bring this form with you to the Netherlands.
Annex II
Statement of home institution regarding mastery of the English language
Family name (for married woman maiden name): Di Giacomo

First name(s): Francesco

Date of birth: 21 /4 / 1987 Place of birth: Rome (RM)

Email: digiacomo.francesco@gmail.com

Country of birth: Italy Nationality: Italian

Sex: male female

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Undersigned Coordinator confirms that the mentioned student has a sufficient knowledge of the
English language comparable with:
an original
an original Academic
Academic IELTS IELTS
score score of at6.5
of at least least 6.0 on average
on average
TOEFLscores
oror TOEFL scores
of of
at at least
least 80 (Internet-based), 213 (computer-based) or 550 (paper-based).
90 (Internet-based).

Name coordinator:
Date:

Signature coordinator Stamp institution