Erasmus+ project No.   2018-1-HR01-KA107-047067

APPLICATION FORM

	PERSONAL DATA OF THE APPLICANT				
	NAME(S)					
						
	SURNAME(S)					
						
	Academic title / degree					
						
	Date of birth					
						
	Place and country of birth					
						
	Citizenship					
						
	Gender		M	F		
						
	Personal Identity Number					
						
	Permanent address					
						
	Temporary address					
	(if different than the permanent					
	address)					
	Phone number					
						
	Mobile phone number					
						
	E-mail address					
						
	Disability status or special needs		yes	no		
						
	If yes, provide short description of the					
	disability or special needs with					
	reference to mobility realization					
						
	EMPLOYMENT DATA OF THE APPLICANT				
	Home University (employer)					
						
	Home faculty / department / chair /					
	office					
						
	Title of the job position					
						
	Scientific or teaching title / degree					
	(only for teaching staff)					
					
	Employment status at home University		Full-time employment (permanent employment contract)		
	(mark relevant information)		Part-time employment (Employment contract valid until dd/mm/yyyy)		
			Part-time associate (agreement on cooperation with the home university		
			valid until dd/mm/yyyy)			

LANGUAGE COMPETENCES

Mother tongue

Language to be used during the

Erasmus+ mobility realization

DATA ABOUT THE HOST (RECEIVING) UNIVERSITY IN A PARTNER COUNTRY

Receiving University

Receiving faculty
Department / chair

Address, city and country

Web page

Contact person at the receiving University

Position of the contact person

Phone of the contact person

E-mail of the contact person

PROPOSED MOBILITY AT THE HOST (RECEIVING) UNIVERSITY
Planned mobility period
day-month-year – day-month-year

Total number of mobility days				
(without travel days included)				
Number of travel days requested for funding				
(max. 2 days)				
Purpose of the Erasmus+ mobility	Staff training	Teaching		
(mark relevant information)				
				
Mobility Flow Reference Number (as indicated in				
the Mobility Flow Plan)				

DOUBLE FINANCING DISCLAIMER

If awarded financial support for the above proposed Erasmus+ mobility, I declare that I will not use other funding resources for the realization of proposed mobility that originate from the European Union funds or programmes.

Signature

CONSENT TO DISCLOSURE OF PERSONAL INFORMATION

By submitting my application, I affirm that I have read and understood all provisions of the Call for Applications within the Erasmus+ project no. 2018-1-HR01-KA107-047067and that I give my consent to coordinating HEI, the Polytechnic of Međimurje in Čakovec, to publicly disclose my name, my personal information and my mobility activity data before, during and after the mobility. 

Signature

Place and date of application submission:

Note: this form has to be signed and scanned together with other application documents and sent to e-mail:  mmiscasncuk@mev.hr     or      erasmus@mev.hr until the deadline defined in the call.

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