A national network of graduate schools of engineering
within France’s leading science universities
APPLICATION FORM
BRAFITEC Program
Photo
This form should preferably be completed on a computer.
If you write by hand please use black ink and capital letters.
Institution you apply for:
Polytech’Orléans
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Field of study :………………………………………
SENDING INSTITUTION
Name of sending institution : ..................................................................................................
Full address of sending institution : ........................................................................................
...............................................................................................................................................
Phone: .................................................. Fax: ..........................................................................
Academic supervisor :
Name:....................................................... Phone: ................................................................
Address: .................................................................................................................................
...............................................................................................................................................
Fax: ............................................................ E-mail: ................................................................
Contact person at the International Office :
Name:......................................................... Phone:................................................................
Address: ..................................................... ...........................................................................
................................................................... ...........................................................................
E-mail: ........................................................ Fax: ....................................................................
STUDENT’S PERSONAL DATA
Family name : ...........................................
Gender: M  F 
Nationality:................................................
Current address:
..................................................................
..................................................................
Current address is valid until :....................
Phone: .......................................................
E-mail: .......................................................
Passport number: ......................................
Valid until: ..................................................
Application Form BRAFITEC
First name: ........................................................
Date of birth (dd/mm/yy): ...................................
Place of birth: ....................................................
Permanent address (if different):
.........................................................................
.........................................................................
.........................................................................
.........................................................................
Phone : .............................................................
E-mail : .............................................................
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Person to notify in case of emergency :
Name:.......................................................
E-mail: ......................................................
Phone: ...............................................................
STUDIES AT HOME INSTITUTION :
Present field of study : ..........................................................................................................
College/Department : ...........................................................................................................
Final degree : ........................................................................................................................
To be obtained by (date) : .....................................................................................................
EDUCATION
Year
Name of the University
College name
Specialization
FOREIGN LANGUAGE PROFICIENCY
Language
I am currently studying
this language
I have sufficient
knowledge to follow
lectures
yes
no
yes
no
French
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English
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Other:……….
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……………….
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Application Form BRAFITEC
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Number of years of
study
LEARNING AGREEMENT
ACADEMIC YEAR 20…./ 20…..
FIELD OF STUDY: .....................................................
Name of student:………………………………………………………………………………………...
Sending institution: ...................................................... Country : ..............................................
DETAILS OF THE PROPOSED STUDY PROGRAMME ABROAD/LEARNING AGREEMENT
Receiving Institution:
Polytech’Lille
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Polytech’Marseille 
Polytech’Orléans 
Course code
Course title
If necessary, continue this list on a separate sheet
Student’s signature: .................................................................. Date: .......................................
SENDING INSTITUTION
We confirm that this proposed programme of study/learning agreement is approved.
Academic Coordinator’s signature
Head of International Office
............................................... Date: ............
.................................................. Date:...........
RECEIVING INSTITUTION
We confirm that this proposed programme of study/learning agreement is approved.
Academic Coordinator’s signature
Head of International Office
Date:……..
Date:……..
Application Form BRAFITEC
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