ATTACHMENT 1

Facsimile form to participate in the call for applications for student mobility grants

Faculty of Civil and Industrial Engineering
Academic year 2018-2019 (2nd semester – only for theses)
Academic year 2019-2020

		To the Dean
of the Civil and Industrial Engineering Faculty
Sapienza University of Rome

I, the undersigned ……………………………………………………… matriculation n. …………..born in............................................................................ on the ……………………... tax code ………………………….……………… resident in ……………………………………… province .......... via/piazza ………………………………………......…………….. n. … telephone.……………………………… and living in via/piazza (only if different from the residence address)  ……………………..…………………………............. n. ... province .......... telephone.…………………………… mobile phone number…………………….................. e-mail address for future communications............................................................................................,enrolled in the AY ……………….. at Sapienza University of Rome in the ……….…year of the Bachelors Degree/Masters Degree,/Specialization Programme/PhD.........................................................of the Faculty of di Civil and Industrial Engineering,  asks to participate in the call for applications for student mobility grant to study in one of the following host Institutions that are listed in order of preference:

1.	………
2.	………
3.	………
To this end I, the undersigned, declare according to the Legislative Decree 445/2000 under my own responsibility and aware that providing false or incomplete statements is a criminal offense, that:
I attach to this letter, in compliance with the provisions of art. 5.2 of the call for applications, the self-certification of the exams I sat specifying the grades/credits I achieved;

1.	I attach a copy of a certificate confirming that I possess the English language knowledge that is required to attend the courses of the University listed in Annex 2, as prescribed by art. 2.3.2 of the call for applications;

2.	I am in good standing with the payments of my taxes, contributions, arrears or any pending payments for the academic year 2017/2018 and 2018/2019 for departures during the academic year 2019/2020 and during the period of my mobility;

3.	I attach a general plan of the exams that I wish to attend abroad that is inline with my curriculum at Sapienza, and that has been approved by my reference professor (s);

4.	I attach (for candidates who will carry out research abroad), a brief summary of my thesis research project, and a letter of my supervisor confirming that I have been assigned the thesis and approving the program I have set up;

5.	I want to stay a student until the end of my study period abroad since this period is considered as an integral part of my curriculum at my home University. 

6.	I am not benefitting at the same time from other grants paid by Sapienza University  for international exchanges or stays abroad. 

7.	I authorize the treatment of my personal and sensitive data according to the new European Regulation no. 679 of 27.4.2016 - GDPR (General Data Protection Regulation) as well as to the current national legislation.

Date……………………………..
Signature

……………………………….
List of sat exams:
Subjects	Grades	Credits	
1.			
2.			
3.			
4.			
5.			
6.			
7.			
8.			
9.			
10.			
11.			
12.			
13.			
14.			
15.			

Possible partial credits
Subjects/Internship	Credits	
1.		
2.		
3.		
4.		
5.		

I, the undersigned, aware of the responsibilities I assume before the law through this act, as well as of the consequences that may arise in the event of false or incomplete declarations or of declarations that contain data that does not correspond to the truth, fully confirm that the aforementioned information regarding the exams I have sat is true.

Date………………………..
Signature
……..…………………………………

LEARNING AGREEMENT TO APPLY

ACADEMIC YEAR 20..../20.... – STUDY PROGRAMME: .........................................................................

NAME and SURNAME: ..................................................................................................................................................
HOST UNIVERSITY: ……………………………………………………………
COUNTRY: ……………..
MOBILITY PERIOD: from………………………………………to……………………………..	

Code of the Study Programme 	Courses to be attended abroad	Number of credits abroad	Recognized courses at Sapienza	Number of ECTS	

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Signature of the student: ........................................................................ Date: ..................................................	

Signature of the Professor of the Programme/responsible for the agreement 
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Stamp and date: .......................................................................................................................................