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 or ID card)

	Passport number 
Date of Expiry	
Telephone Number:
Mobile Number:
	E-mail Address:	
Do you require Disability Support?     
	Yes ☐     No ☐	

HOME UNIVERSITY	
Home University:	UNIBG	
Current position at the Home university:
•	Unit; 
•	Phone and mobile numbers, main activities);

•	Professional role: 
Manager(Dirigente), Administrative staff (PTA), Language teaching staff (CEL);

•	Employment contract: 
Fixed-term contract (TD) – indicate expiration date - Permanent work contract (TI);

•	Previous mobility experiences (Overseas programme, Erasmus Staff Training, etc.)

HOST UNIVERSITY	
Host University 
	EGE RABAT	
Duration of stay (n° of days):
		
Proposed dates of stay: 

The undersigned is willing to apply for the Erasmus+ - International Credit Mobility grant to ………………………………………………………..,  according with the call for applications published on …………..…….. with the following deadline: 

Compulsory attachments:

□	Copy of a valid passport;
□	Mobility Programme signed by the applicant and the Head of the applicant’s Administrative Unit;
□	Copy of official language certifications if available; 
□	Curriculum Vitae (max 2 pages) in English including extra-curricular activities and professional experience related to the activities of the mobility. Please use the European template on https://europass.cedefop.europa.eu/en/documents/curriculum-vitae/templates-instructions.iehtml;
□	Communication by the prospective academic/administrative supervisor of the host university stating the availability and willingness to host the applicant

Data protection
Information relating to individuals (personal data) is collected and used in accordance with EC Regulation No 45/2001 of the European Parliament and of the Council on the protection of individuals, and  with Italian legislation (Legislative Decree no. 196/2003 and EU GDPR. 25/5/2018) with regard to the processing of personal data by European institutions and organizations and the unrestricted circulation of such data.

SIGNATURE OF APPLICANT	
I confirm that all the information provided on this application form and attached documents  are correct according to DPR 445/2000, art. 46 and 47. I’m also informed of the penal liability under Art. 76 of DPR 445/2000 for the case of false documents and false statements therein.	
Signature: 

	Place and Date:	

SENDING INSTITUTION 	
We confirm that the attached proposed mobility programme is approved.
Head of the applicant’s Administrative Unit   _______________________________________   
Signature    __________________________________________________________________

Date:     	
HOST INSTITUTION – EGE RABAT	
We confirm that the attached proposed mobility programme is approved by the following Academic/Administrative Unit:
…..
EGE International Office Coordinator    _______________________________________   
Signature    __________________________________________________________________

Date: