Author: Tina
Last saved by: Domagoj

Erasmus+ project No. 2026-1-HR01-KA171-HED-000427502

APPLICATION FORM

| PERSONAL DATA OF THE APPLICANT | | |
| NAME | | | |
| SURNAME | | | |
| Academic title / degree | | | |
| Date of birth | | | |
| Place and country of birth | | | |
| Citizenship | | | |
| Gender | | M | F |
| Personal Identity Number | | | |
| Permanent address | | | |
| Temporary address | | | |
| (if different than the permanent | | | |
| address) | | | |
| Phone number | | | |
| Mobile phone number | | | |
| E-mail address | | | |
| Disability status or special needs | | yes | no |
| If yes, provide short description of the | | | |
| disability or special needs with | | | |
| reference to mobility realization | | | |
| EMPLOYMENT DATA OF THE APPLICANT | | |
| Home University (employer) | | | |
| Home faculty / department / chair / | | | |
| office | | | |
| Title of the job position | | | |
| Scientific or teaching title / degree | | | |
| (only for teaching staff) | | | |
| Employment status at home University | | Full-time employment (permanent employment contract) |
| (underline relevant information) | | Part-time employment (Employment contract valid until dd/mm/yyyy) |
| | | Part-time associate (agreement on cooperation with the home university |
| | | valid until dd/mm/yyyy) | |

1

LANGUAGE COMPETENCES

Mother tongue

Language to be used during the

Erasmus+ mobility realization

DATA ABOUT THE HOST (RECEIVING) UNIVERSITY IN A PARTNER COUNTRY

Receiving University

Receiving Faculty
Department / chair

Address, city and country

Web page

Contact person at the receiving University

Position of the contact person

Phone of the contact person

E-mail of the contact person

PROPOSED MOBILITY AT THE HOST (RECEIVING) UNIVERSITY
Planned mobility period
DD-MM-YYYY – DD-MM-YYYY

Total number of mobility days | | |
(without travel days included) | | |
Number of travel days requested for funding | | |
(max. 2 days) | | |
Purpose of the Erasmus+ mobility | Training | Teaching |
(underline  relevant information) | | |
Mobility Flow Reference Number (as indicated in | | |
the Mobility Flow Plan) | | |

DOUBLE FINANCING DISCLAIMER

If awarded financial support for the above proposed Erasmus+ mobility, I declare that I will not use other funding resources for the realization of proposed mobility that originate from the European Union funds or programmes.

Signature

CONSENT TO DISCLOSURE OF PERSONAL INFORMATION

By submitting my application, I affirm that I have read and understood all provisions of the Call for Applications within the Erasmus+ project no. 2026-1-HR01-KA171-HED-000427502 and that I give my consent to coordinating HEI, the University North, to publicly disclose my name, my personal information and my mobility activity data before, during and after the mobility.

Signature

Place and date of application submission:

Note: this form has to be signed and scanned together with other application documents and sent to e-mail:  mobilnost@unin.hr until the deadline defined in the Call.