| Given/first
name |
|
| Family
name |
|
| Date
of birth | Day
Month
Year |
| Four
last numbers/P-number (if you have studied at LiU before) |
|
|
Gender |
|
| Citizenship |
|
Current address |
| Valid
from (date yy-mm-dd) |
|
| Valid
to (date yy-mm-dd) |
|
| C/O
(name on the door if it is different from your own name) |
|
|
Street and number |
|
|
Postal code |
|
| City |
|
| Country |
|
|
Email |
|
| Telephone
number (incl country code) |
|
| Mobile/cell
phone |
|
Alternative
address (always
valid - Example: parents' address) |
| Valid
from (date yy-mm-dd) |
|
| Valid
to (date yy-mm-dd) |
|
| C/O
(name on the door if it is different from your own name) |
|
| Street
and number |
|
| Postal
code |
|
| City |
|
| Country |
|
|
Email |
|
| Telephone
number (incl country code) |
|
| Mobile/cell
phone |
|
Academic
Data |
|
Exchange Programme |
|
|
Sending university |
|
If your university is not in the list please write the name here |
|
|
Study programme |
|
|
Current semester of study |
|
Coordinator/Contact person at sending university (incl telephone, fax, and
e-mail) |
|
|
| |
| Theoretical
modules: |
| 1st
module |
| |
| 2nd
module (not compulsory) | | |
| 3rd
module (not
compulsory) | | |
|
| Clinical
modules | | Number
of weeks |
| 1st
choice
| | |
| 2nd
choice | | |
| 3rd
choice | | |
| 4th choice
|
| |
| 5th
choice |
| |
| | | Number of weeks |
| 1st choice | | |
| 2nd
choice | | |
| 3rd
choice | | |
| 4th
choice | | |
| 5th
choice | | |
| | | Number
of weeks |
| 1st
choice | | |
| 2nd
choice | | |
| 3rd
choice | | |
| 4th
choice (if the first three are not possible) | | |
| 5th
choice (if
the first three are not possible) | | |
| Course
| |
| Course
| |
| Course
| |