ࡱ>     +bjbj qqcce%6  _____sss8 sE:?&?&?&/D1D1D1D1D1D1D$zH0KPUD_?&K%?&?&?&UD__pZES3S3S3?& __/DS3?&/DS3S35=hq>@gO`%/2=DpE0E=K1`K q>q>K_3??&?&S3?&?&?&?&?&UDUDS3?&?&?&E?&?&?&?&K?&?&?&?&?&?&?&?&?& %:  PRE-APPLICATION FORM FOR DOUBLE DEGREE PROGRAM (for pre-selection of Bachelor 4 Year students) DOSSIER DE PRE-CANDIDATURE POUR PROGRAMME DE DOUBLE DIPLOME (pour pr-slection dtudiants en 4me anne de licence) Applicants name Nom du candidat: Academic year Anne acadmique : 201 / 201 ADMISSION PROCEDURE PROCEDURE DADMISSION 1/ Fill in this application form (in black ink and block capitals if hand-written) and sign it Compltez le dossier (au stylo noir et en majuscules, si crit la main) puis signez-le 2/ If you are an exchange student, submit your application and your learning agreement to the exchange coordinator at your home university, for approval Si vous venez dans le cadre dun change, soumettez votre dossier et votre contrat dtudes au coordinateur de votre tablissement dorigine, pour validation. 3/ Return your application (scanned version of this form + all the documents listed below) by email only to: Retour en un seul fichier et seulement par e-mail (version scanne de ce formulaire + tous les documents demands ci-dessous) :  HYPERLINK "mailto:nadine.lenenaon@ensam.eu" nadine.lenenaon@ensam.eu and  HYPERLINK "mailto:yvon.velot@ensam.eu" yvon.velot@ensam.eu Application deadline : 31st October 2016 for all degree seeking students starting in September Dates limites de candidature : 31 octobre 2016 pour tous les tudiants venant pour obtenir un diplme (dbut des cours en septembre)  For any questions or concerns, please contact: Pour toute question, contactez:  HYPERLINK "mailto:yvon.velot@ensam.eu" yvon.velot@ensam.eu CHECKLIST Please use the checklist below to ensure that your application is complete before sending. Incomplete or non complying applications will not be processed. Merci dutiliser la liste ci-dessous pour vous assurer que votre dossier est bien complet avant de lenvoyer. Les dossiers incomplets ou non conformes ne seront pas traits. & Arts et Mtiers ParisTech application form ensuring that every section is completed Dossier de candidature Arts et Mtiers ParisTech. Assurez-vous de bien complter chaque partie & Transcripts of records at university level (certified by the awarding institution) Relev de notes universitaires (certifi par l tablissement) & Ranking certificate (certified by the awarding institution) Attestation de classement (certifi par l tablissement) & Copy of highest university degree (if any) Copie du diplme le plus lev & Copy of passport or ID card Copie du passeport ou de la carte d identit & Curriculum Vitae & Proof of language proficiency (if available) Attestation de comptence en langue (si disponible)  STUDENT S PERSONAL DATA INFORMATIONS PERSONNELLES Please insert a (recent) photo Merci de coller une photo (rcente) Family Name Nom First name(s) Prnom(s) Nationality Nationalit Gender Sexe: M & F & Date of birth (dd/mm/yy) Date de naissance (jj/mm/yy) ______ / ______/ ___________ Place of birth Lieu de naissance Correspondence addressAdresse de correspondance Postcode and city Code postal et ville Country Pays Permanent address (only if different) Adresse permanente (seulement si diffrente) Postcode and city Code postal et ville Country Pays Address for admission letter Adresse de rception de la lettre d admission: & Correspondence address Adresse de correspondance & Permanent address Adresse permanente Tel + __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Email Applicant s name/nom du candidat: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .. ACADEMIC BACKGROUND PARCOURS ACADEMIQUE From (month/year) Dbut (mois/anne)Until (month/year) Fin (mois/anne)University name, city and country Nom de luniversit, ville et paysLevel/Degree Anne, diplmeMajor field of study Domaine dtudesResults (Grade, %) Rsultats (Classement, %) CURRENT INSTITUTION ETABLISSEMENT ACTUEL Name of current (or last attended) university Nom de votre tablissement actuel (ou dernier tablissement frquent) Address Adresse Contact person (Departments or Universitys International Coordinator) Responsable relations internationales Address, phone n, e-mail Adresse, tlphone, e-mail Applicants name/nom du candidat: .. EMPLOYMENT HISTORY EXPERIENCES PROFESSIONNELLES INTERNSHIPS STAGES Type of work experience Fonction occupeCompany/organisation Entreprise/organismeDates DatesCity and country Ville et pays FULL-TIME JOBS EXPERIENCES PROFESSIONNELLESType of work experience Fonction occupeCompany/organisation Entreprise/organismeDates DatesCity and country Ville et pays Comments Commentaires Please attach proof of internship or job Merci de joindre une attestation de stage ou demploi  Applicants name/nom du candidat: .. LANGUAGE SKILLS COMPETENCES LINGUISTIQUES Mother tongue Langue maternelle Please check all language requirements on our website Merci de vrifier sur notre site Internet les niveaux de langue demands FRENCH FRANAIS Beginner Dbutant Intermediate Intermdiaire Advanced Avanc Listening Comprhension orale Reading Comprhension crite Speaking Expression orale Writing Expression crite & & & & & & & & & & & & ( ( ( ( Language test Test de langue (type, score, date) Please attach a copy Merci de joindre une copie I don t speak this language Je ne parle pas cette langue & ENGLISH ANGLAIS Beginner Dbutant Intermediate Intermdiaire Advanced Avanc Listening Comprhension orale Reading Comprhension crite Speaking Expression orale Writing Expression crite & & & & & & & & & & & & ( ( ( ( Language test Test de langue (type, score, date) Please attach a copy Merci de joindre une copie I don t speak this language Je ne parle pas cette langue & OTHER LANGUAGE AUTRE LANGUE& & & & & & & & & & & & & & & & & & .. 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MOTIVATIONS MOTIVATIONS Describe your academic interests and reasons for applying (Study project). What are your motivations? What are your plans after completing this program (Professional Project)? Merci de dcrire brivement les raisons de votre candidature (Projet dtudes). Quelles sont vos motivations? Quels sont vos projets incluant ce programme(Projet professionnel)?  Applicants name/nom du candidat: (if applicable/si pertinent): Sending university/Univ. dorigine: YOUR STAY AT ARTS ET METIERS VOTRE SEJOUR DETUDES A ARTS ET METIERS Apply for the program Candidatez au programme: Step 1: Indicate the program Indiquez le programme: & Engineer s Degree (for applicants coming from partner universities only) Diplme d ingnieur (seulement pour les candidats venant d une universit partenaire) Step 2: If your stay includes semesters 9 and/or 10, list three final year courses (Advanced teaching Unit or MSc) you are interested in Si votre schma dtudes comprend les semestres 9 et/ou 10, listez trois cours de dernire anne (Enseignement dexpertise ou Master Recherche) qui vous intressent 1st choice/choix n1 2nd choice/choix n2 3rd choice/choix n3 Step 3: Fill in and sign the Learning agreement, page 8 (applicants coming from partner universities only) Remplissez et signez le contrat dtudes, page 8 (seulement les candidats venant dune universit partenaire) Starting date Date de rentre & September Septembre Expected duration of stay Dure prevue de sjour : from du & & & & & & & & & & to au & & & & & & & & & & & & & Exchange program Programme d changes (to be completed only if necessary complter seulement si ncessaire) & Double degree Double diplme  & I declare that the information provided in this application and the supporting documents are exact. Je dclare sur l honneur l exactitude des informations transmises dans ce dossier de ;=>KqcWWW p#dgd $ p#ba$gd %~kd,$$Ifl#H$  t 0644 l` ap ytc p#d$Ifgdc9=>?JK\kgP@+(hchHCJOJQJ^JaJmH sH hHCJOJQJaJmH sH ,hchH6B*OJQJ^JmH phsH /hchH56B*OJQJ^JmH phsH  hchckCJOJQJ^JaJ hch %CJOJQJ^JaJhch26CJOJQJaJhch2CJOJQJaJhchckCJOJQJaJhch %CJOJQJaJjhcUmHnHu hNhhchOJQJaJ[ "$&(*, p#gdgdgdH p#dgdH d7$8$gdH6$ p#$d%d&d'd-DM yUNOPQa$gdHAXYZ[?@mstu®—®ˆyj[L>jhcUmHnHuhchckCJOJQJaJhY@h2CJOJQJaJhY@hgCJOJQJaJhY@hLAcCJOJQJaJhY@hHCJOJQJaJ,hch|6B* CJOJQJ^JaJphyU&hKZ6B* CJOJQJ^JaJphyU,hchH6B* CJOJQJ^JaJphyU(hchHCJOJQJ^JaJmH sH "hKZCJOJQJ^JaJmH sH ,.02468:<>@BDFHJLNPRTVXZ\^`ce p#gdgegikmoqstv\6$ p#$d%d&d'd-DM yUNOPQa$gdOyn p#dgdLAc $ p#ba$gd %$ p#da$gd % $ p#ba$gdck p#gd2 p#gdg uv34Aðo\I6$hchVV6B*OJQJ^Jph$hchC5B*OJQJ^Jph$hchVV5B*OJQJ^Jph$hDh %CJOJQJaJmH sH .hDh %6CJOJQJ\^JaJmH sH +hDh %CJOJQJ\^JaJmH sH $hDh %CJOJQJaJmH sH #hch %CJOJQJ\^JaJhch %6CJOJQJaJhch %CJOJQJaJh %CJOJQJaJAJ[\]fjrst~dzkS77hKZh K56B* CJOJQJ^JaJmH phyUsH 7hKZh56B* CJOJQJ^JaJmH phyUsH .hKZh>O85CJOJQJ\^JaJmH sH .hKZh55CJOJQJ\^JaJmH sH .hKZhKZ5CJOJQJ\^JaJmH sH .hKZh5CJOJQJ\^JaJmH sH &hch5CJOJQJ\^JaJ$hch- ;6B*OJQJ^Jph$hchVV6B*OJQJ^Jph$hchl6B*OJQJ^Jph \]TV{{{III2d$d%d&d'd-DM NOPQgdc9 p#d$d%d&d'd-D7$8$M NOPQgdc<$ p#d$d%d&d'd-D7$8$M NOPQa$gdc p#d7$8$gdh~ʮzfTET4fT hKZ5CJOJQJ\^JaJhKZCJOJQJ\^JaJ#hch'CJOJQJ\^JaJ&hch'5CJOJQJ\^JaJ.hKZh5CJOJQJ\^JaJmH sH 7hKZh =56B* CJOJQJ^JaJmH phyUsH 7hKZh556B* CJOJQJ^JaJmH phyUsH 7hKZh56B* CJOJQJ^JaJmH phyUsH 1hKZ56B* CJOJQJ^JaJmH phyUsH  *վjT<$.hch.>X5CJOJQJ\^JaJmH sH .hch.>X5CJOJQJ\^JaJmH sH +hch.>XCJOJQJ\^JaJmH sH (hchiCJOJQJ^JaJmH sH (hch` GCJOJQJ^JaJmH sH /hchXCJOJPJQJ^JaJmH o(sH #hch =CJOJQJ\^JaJ,hch?6B* CJOJQJ^JaJphyU,hch2s6B* CJOJQJ^JaJphyU&hKZ6B* CJOJQJ^JaJphyU RTV`bdfrtη{j{XF4F4#hchvqvCJOJQJ\^JaJ#hchACJOJQJ\^JaJ#hch'CJOJQJ\^JaJ hKZ5CJOJQJ\^JaJ&hch'5CJOJQJ\^JaJ,hch6B* CJOJQJ^JaJphyU hchiCJOJQJ^JaJ,hch.>X6B* CJOJQJ^JaJphyU,hchi6B* CJOJQJ^JaJphyU4hch6B* CJOJQJ^JaJmH phyUsH  345Nx~w`I2,hch2s6B* CJOJQJ^JaJphyU,hch'6B* CJOJQJ^JaJphyU,hchA6B* CJOJQJ^JaJphyU,hchvqv6B* CJOJQJ^JaJphyU,hch?6B* CJOJQJ^JaJphyU#hch8SCJOJQJ\^JaJ#hchACJOJQJ\^JaJ#hchPCJOJQJ\^JaJ#hchvqvCJOJQJ\^JaJ#hch1DGCJOJQJ\^JaJ һ{dUF{2{d&hch*CJH*OJQJ\^JaJh6~Dh*CJOJQJaJh6~DhHCJOJQJaJ,hch*6B* CJOJQJ^JaJphyU#hch*CJOJQJ\^JaJ,hchh6B* CJOJQJ^JaJphyU,hch =6B* CJOJQJ^JaJphyU,hchA6B* CJOJQJ^JaJphyU,hchvqv6B* CJOJQJ^JaJphyU,hch8S6B* CJOJQJ^JaJphyU V  `b><$ J d$d%d&d'd-D7$8$M NOPQa$gdcH$gdH9 p#d$d%d&d'd-D7$8$M NOPQgdc   %&'()-ĭvbQb?-?#hch]CJOJQJ\^JaJ#hchPCJOJQJ\^JaJ hKZ5CJOJQJ\^JaJ&hchP5CJOJQJ\^JaJ&hch^( 5CJOJQJ\^JaJ&hchm 5CJOJQJ\^JaJhY@h^( CJOJQJaJ,hch^( 6B* CJOJQJ^JaJphyU#hch^( CJOJQJ\^JaJhHCJOJQJaJhY@hHCJOJQJaJhY@h*CJOJQJaJ-9=QW۷u^G/G^G/hchP56B* CJOJQJ^JaJphyU,hchP6B* CJOJQJ^JaJphyU,hch 36B* CJOJQJ^JaJphyU,hchd6B* CJOJQJ^JaJphyU,hch]6B* CJOJQJ^JaJphyU&hchP5CJOJQJ\^JaJ#hch]CJOJQJ\^JaJ#hchdCJOJQJ\^JaJ#hchPCJOJQJ\^JaJ#hchuCJOJQJ\^JaJ6^`bz,28D^`bӼӼӼӼzhӼhV;5hchqB*CJOJPJQJ^JaJnH phtH "h}2h\ 5CJOJQJ\aJ#hch\ 6CJOJQJ^JaJ#hchd6CJOJQJ^JaJ0hch\ B* CJOJPJQJ^JaJo(phyU,hchbw6B* CJOJQJ^JaJphyU,hch\ 6B* CJOJQJ^JaJphyU hch\ CJOJQJ^JaJ5hchYB*CJOJPJQJ^JaJnH phtH b<>@Bb~ŮucO>> hchEKCJOJQJ^JaJ'hchEKCJOJPJQJ^JaJo("h6~DhEK56CJOJQJaJ,hchEK6B* CJOJQJ^JaJphyUh6~DhEK6CJOJQJaJ#hchEK6CJOJQJ^JaJ,hchEK6B* CJOJQJ^JaJphyU/hchEK56B* CJOJQJ^JaJphyUh6~DhEK5CJOJQJaJ#hchEK5CJOJQJ^JaJ >@VR(T(,)**ummmmma $ ] a$gd$a$gd $ p#ba$gdD $H$a$gd %9 J $d%d&d'd-D7$8$M NOPQgdcm$9$ J $d%d&d'd-D7$8$M NOPQa$gdc DRTV(ŭnW9" U,hch6B* CJOJQJ^JaJphyU:hch56B* CJOJQJ\^JaJmH phyUsH ,hchO6B* CJ^JaJmH phyUsH (hch@UCJOJQJ^JaJmH sH (hchOCJOJQJ^JaJmH sH (hchCJOJQJ^JaJmH sH /hch~CJOJPJQJ^JaJmH o(sH  hchCJOJQJ^JaJjhcUmHnHu5hch %B*CJOJPJQJ^JaJnH phtH  candidature ainsi que des pices jointes & I authorize Arts et Mtiers ParisTech to check, store and process my data as required for my application. J autorise Arts et Mtiers ParisTech utiliser, vrifier et stocker les informations du dossier de candidature Date ____/______/20_____ Applicants name and signature Nom de ltudiant et signature Conformment la loi informatique et liberts du 6 janvier 1978 modifie en 2004, vous bnficiez dun droit daccs et de rectification aux informations qui vous concernent, que vous pouvez exercer en vous adressant la Direction Gnrale des Relations Internationales dArts et Mtiers ParisTech.     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