FICHE D'ACCUEIL

FORMATION - ECOLE POLYTECHNIQUE 91128 PALAISEAU CEDEX NOM Prnom: (Family name and first name). Date de naissance : .// (Date of birth) Nationalit actuelle : (Current citizenship) Catgorie et numro de passeport - autorit l'ayant dlivr (Passport number and name of the authority which delivered it) Fils de (your fathers family name and first name) et de (your mothers name before she got married and her first name) Mari (e) Nom et prnom du (de la) conjoint (e). (If you are married, family name and first name of husband/wife) nombre d'enfants : (How many children, if any) Adresse dans le pays d'origine : (Full permanent address in home country) Adresse en France: (Address in France) Connaissance de la langue franaise : (your level in French) Autres langues parles : (Other spoken languages) Niveau scolaire : (Number of years of study at the university, after highschool) Diplmes dtenus civils : (Name of university degree, if any) Brevets civils : (Only for military staff) Ecoles frquentes (civiles ou militaires) :. (Name of your home university) Sports pratiqus (Sports practiced at leisure time or in competition) Affectations successives (5 dernires annes) (Only for military staff) 1/2
Annexe 14 SPIS/Scurit dit.05/12/02

Lieu de naissance: (Place of birth town and country) ancienne (ventuellement) : (Previous citizenship, if any)

Ecrites : (other written languages)

Militaires : (Only for military staff) Militaires : (Only for military staff)

Emploi (s) prcdent (s) : (Last professional position) Sjours ou stages effectus en France : (Previous stays in France Tourism, studies, etc..) Date : Date :

quel titre (purpose) : quel titre (purpose ) :

Sjours ou stages effectus l'tranger (Previous stays in Foreign countries other than France Tourism, studies,..) Date : Pays (Country) : quel titre (purpose) : Date : Date : Pays (Country) : Pays (Country) : quel titre (purpose) : quel titre (purpose) :

Personne prvenir en cas d'accident (In case of accident, full reference of the person who should be contacted): En France in France Nom prnom (Family name and first name): Adresse (Full address) : Tlphone (Telephone Number) : Dans votre pays in your home country Nom prnom (Family name and first name): Adresse (Full address) : Tlphone (Telephone number) : Adresse de cong en France :

Famille rsidant en France Family members living in France, if any Nom prnom (Family name and first name): Adresse (Full address) : Tlphone (Telephone number) : Important: Joindre deux photographies d'identit rcentes (inscrire le nom au dos des photos) ainsi que la photocopie du passeport et de la carte de sjour. (Please join two identity photos, in French standards, and copy of passport and/or resident permit) Signature du stagiaire

Conformment la loi Informatique et Liberts, vous bnficiez dun droit daccs et de rectification aux informations qui vous concernent. Si vous souhaitez exercer ce droit et obtenir communication des informations vous concernant, veuillez vous adresser votre demande par crit : Ecole Polytechnique SG/MG - Bureau Scurit Route de Saclay 91128 Palaiseau Cedex The information collected by Ecole Polytechnique is computerized. In accordance with the law Informatique et Liberts, you can assert your right to access and correct the information related to you. If you want to exercise this right and receive the information related to you, please send a written request to : Ecole Polytechnique SG/MG Bureau Scurit Route de Saclay 91128 Palaiseau Cedex

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Annexe 14 SPIS/Scurit dit.05/12/02

FICHE B/10 An.III

ANNEXE III
_________

FICHE DE CONTROLE DE RESSORTISSANT ETRANGER

_______________ Nationalit (Citizenship) : .. NOM (Family name) :.Prnoms (First name) Date (jj/mm/aaaa) et lieu de naissance (Date and place of birth Town and country) .... NOM Prnoms (pre)(mre nom de jeune fille) .. (Fathers family name and first name) (Mothers maiden name and first name) Domicile dans le pays dorigine : ... (Full address in home country) .. .. Rsidence actuelle en France : (Current address in France) Grade militaire ou titre civil : ... (Military or civil position) Spcialit militaire ou technique : Documents didentit consults : .. .. But du stage ou de la visite : .. Rfrence de lautorisation de commandement : ... Dure : .Date de dbut : ..Date de fin : ... Eventuellement : lintress arrive de lorganisme franais suivant (appellation, lieu de
stationnement) :.

A ., le Lofficier de scurit
Conformment la loi Informatique et Liberts, vous bnficiez dun droit daccs et de rectification aux informations qui vous concernent. Si vous souhaitez exercer ce droit et obtenir communication des informations vous concernant, veuillez vous adresser votre demande par crit : Ecole Polytechnique SG/MG - Bureau Scurit Route de Saclay 91128 Palaiseau Cedex The information collected by Ecole Polytechnique is computerized. In accordance with the law Informatique et Liberts you can assert your right to access and correct the information related to you. If you want to exercise this right and receive the information related to you, please send a written demand to : Ecole Polytechnique SG/MG Bureau Scurit Route de Saclay 91128 Palaiseau Cedex

Ecole Polytechnique 91128 Palaiseau CEDEX FRANCE

Physical examination
Physical examination must be within 12 months prior to the arrival at Ecole Polytechnique Student name : LAST (FAMILY) FIRST MIDDLE date of birth : Month/Day/Year

Do you feel that the student has a health-related handicap that could affect his/her studies ? Explain : Physical examination : Weight : Height : BMI : Blood pressure: Pulse :

Please answer all questions. Circle Y for yes or N for no. If yes. explain on additional sheet. Has the patient had : insomnia chicken pox Gum/ tooth trouble Malaria Sinusitis Eye trouble Ear, nose, throat trouble Appendicectomy tonsillectomye hernia Other surgery YN YN YN YN YN YN YN YN YN YN Excessive nervousness Frequent anxiety Depression Recurrent headaches Head injury/ unconsciousness Asthma Tuberculosis Shortness of breath Pain/ pressure in chest Chronic cough YN YN YN YN YN YN YN YN YN YN YN palpitations (heart) high or low blood pressure Joint disease or injury Heart murmur Knee or shoulder problems Back problems Tumor, cancer, cyst Jaundice Stomach or intestinal trouble Gall bladder trouble/ gallstones Recurrent diarrhea YN YN YN YN YN YN YN YN YN YN YN recent weight gain/loss YN

Dizziness, fainting, YN weakness, aralysis eating disorder (restriction, Y N purging, hinging) sexually transmitted disease Y N frequent urination infectious mononucleosis Women only : Irregular periods Sever cramps Excessive cramps Gynecologic disease YN YN YN YN YN YN

Are there at the present time abnormalities of the following systems? If yes, describe fully. Use additional sheet if necessary Normal skin Heent Lymph/ Nodes/ Neck/ thyroid Explain abnormals : Abnormal Chest/ lungs Breast Cartiovascular Normal Abnormal Heart murmur Abdomen Genitourinary Normal Abnormal Extremities Neurologic Normal Abnormal

Is this person under treatment for any medical or mental health problems? If so, describe the problem and the treatment.

In your opinion, is there any contraindication for this person to practice a sport? Please elaborate? Do you have any special recommendations for this person's health care?

Address or stamp_________________________________________________________________________________________________ Physician _____________________________________________ Signature Date of physical exam ________________________________________ Month/Day/year

Students declaration: I, undersigned_______________________________certify on my honour to have truly submitted all information to the signatory Doctor of this certificate, in accordance with the Article 7 of the decree dated November 24, 2001 related to the International admissions to the Ingenieur Polytechnicien program of Ecole Polytechnique.

Date and students signature :

The information collected by Ecole Polytechnique is computerized in order to manage the medical file of the students. Only the official doctors of the Army Medical Service will access the information needed to the accomplishment of their duty. In accordance with the law Informatique et Liberts, you can assert your right to access and correct the information related to you. If you want to exercise this right and receive the information related to you please send a written request to : Ecole Polytechnique Service Mdical Route de Saclay 91128 Palaiseau Cedex