APPLICANT’S DETAILS	
Surname 

(as indicated in Passport or Identity card)	First name:

(as indicated in Passport or Identity card)	
Date of birth: (dd/mm/yyyy)	Place and Country of birth:	
Nationality:	Gender: (M/F)	
Residence Address (Indirizzo di residenza): 
(please indicate your full address: Address, Town, Post/Zip Code)		
Document: (passport)	Passport number: 
Date of Expiry:	
Telephone Number:
Mobile Number:	E-mail Address:	
Do you require Disability or Learning Support?     	Yes ☐     No ☐	

HOME UNIVERSITY	
Home University:		
Current position at the Home university:		

HOST UNIVERSITY	
Host University 

PROPOSED PROGRAMME OF TEACHING	
Duration of stay (n° of days):		
Proposed dates of stay: 

The undersigned is willing to apply for the Erasmus+ - International Credit Mobility grant to ……………………………………………………….., 

Compulsory attachments:
-	Mobility Programme signed by the applicant and by the Head of the applicant’s Department;
-	Copy of a valid passport;
-	Copy of official language certifications or, if not available, self-declaration within the Mobility Programme 
-	Curriculum Vitae (max 2 pages) in English including extra-curricular activities (courses, seminars, conferences, published research, etc.) and professional experience related to the fields of the mobility. Please use the European template on https://europass.cedefop.europa.eu/en/documents/curriculum-vitae/templates-instructions.iehtml;
-	Letter of interest signed by the prospective academic supervisor at the host university stating the availability and willingness to supervise the applicant.

SIGNATURE OF APPLICANT	
I confirm that the information provided on this application form is correct.	
Signature: 

	Place and Date: