Erasmus Intensive Programme PCIP
"From Sound to Ultrasound:
Multimedia based Pediatric Cardiology IP"
11th-22nd October 2010, Heraklion, Crete
STUDENT APPLICATION FORM
Date: __________________
Student's Personal Data:
Name: __________________________
Surname: __________________________
Sex: __________________________
Date of birth __________________________
Institute: __________________________
__________________________
Country: __________________________
Student status: Undergraduate (year of studies…….)
Graduate (on Master, PhD, etc)
__________________________
Tel: __________________________
Mob phone: __________________________
E-mail address: __________________________
Home address: __________________________
I certify that I would like to participate in the PCIP 2010 Erasmus Intensive Program, and I have read and understood all terms of participation.
The student CERTIFICATES ENCLOSED
Curiculum Vitae (CV)
Signature, Name and Date
