Registration_form_CPV-studenten_BMW

INSCHRIJFFORMULIER studenten MLW (CPV) / APPLICATION FORM students MLS (ALC)
S.v.p. ALLE vragen invullen en PASFOTO toevoegen / Please fill in completely /add PASSPORT PHOTOGRAPH
CURSUSCODE / COURSE CODE
0060
0061
0062
GEGEVENS AANMELDING/REQUIRED INFORMATION FOR APPLICATION
Achternaam/Family name
Voornaam/First name
Geslacht/Gender
Geboortedatum/Date of Birth
Geboorteplaats/Place of Birth
Geboorteland/Country of Birth
UM-kaartnr./UM-card number
Studentnummer/Student number
Locatie UM (Locatie + afd. + kamernr)
Location UM (Location + dept. + room no.)
Thuisadres (+ postc. + woonplaats)
Home address (+ postal code + city)
Telefoon werk / Telephone work
GSM-Mobiel nr/Mobile number
FTE / Fulltime equivalent
Vakgroep / Department
Faculteit / Faculty
Vooropleiding / Previous Education
Opleidingsplaats/Place of Education (city)
E-mail/E-mail
Datum in dienst/Date of Employment
Datum uit dienst/End of Employment
Promotor/Promotor
Begeleider/Mentor-Supervisor
AIO-niet AIO/Phd student-not Phd student
Kosten worden gedragen door/Funding by
Budgetnummer/Budget number
Not for Master students
Not for Master students
Not for Master students
Not for Master students
Not for Master students
MLW- bachelor
Maastricht
Not for Master students
Not for Master students
Not for Master students
Not for Master students
MLS master (CMS, MHS, ODB) or CBM master
MLS master or CBM master, OIFDG
OVERIGE VEREISTE INFORMATIE/OTHER REQUIRED INFORMATION
Academische graad/Academic degree
BSc afstudeerrichting en –jaar (kopie diploma svp)
BSc and year of graduation (Add copy of diploma)
MSc afstudeerrichting en –jaar (kopie diploma svp)
MSc and year of graduation(Add copy of diploma)
Biologische vooropleiding
List of relevant courses (including BSc studies)
Anatomie/Anatomy
 ECTS (invullen svp)/ECTS (Please fill in)
 SBU (invullen s.v.p.)/Study load (hrs)
Fysiologie/Physiology
 ECTS (invullen svp)/ECTS (Please fill in)
 SBU (invullen s.v.p.)/Study load (hrs)
Andere biologische vakken/Other biological subjects
(attach list with course titles)
 ECTS (invullen svp)/ECTS (Please fill in)
 SBU (invullen s.v.p.)/Study load (hrs)
Not for Master students
Only for students with another education than MLW,
Maastricht 1 week accounts for 1,5 ECTS on average.
1 ECTS corresponds to 28hours study load.
Only for students with another education than MLW,
Maastricht
Only for students with another education than MLW,
Maastricht
- Next page Werkervaring met proefdieren
(bevestiging proefdierdeskundige/leidinggevende bijvoegen !)
Work experience with lab animals
(Please add confirmation letter of animal welfare officer/ supervisor!)
Only for students with another education than MLW Maastricht!
Andere relevante vooropleiding
(in geval van buitenlandse cursus PDK-programma bijvoegen !)
Other relevant courses
(e.g. other course in lab animal science: add detailed programme !)
Only for students with another education than MLW Maastricht!
Please always SEND IN:
*
Copy diplomas (MSc and BSc or others)
Passport photograph
If your previous education was not MLW in Maastricht then also add:
Complete list of all relevant courses with study load (hrs) and ECTS (including BSc studies)
In te vullen door Secretariaat IPC / Secretariat IPC
Aanvraag ter screening naar PDK/Request to animal welfare officer for screening
In te vullen door Proefdierdeskundige / Animal Welfare Officer
Vooropleiding voldoende
Previous Education conform the requirements
Aanvullende vooropleiding vereist – ter screening naar Utrecht
Additional education required / to Utrecht University for screening
Opmerkingen / Remarks:
FORMULIER ZENDEN AAN/PLEASE SEND FORM TO:
[email protected]