ESC RENNES SCHOOL OF BUSINESS 2 RUE ROBERT D ARBRISSEL CS 76522 35065 RENNES CEDEX FRANCE APPLICATION FOR ADMISSION FOR SUMMER PROGRAMME RESPONSIBLE MANAGEMENT 12 June 23 June 2012 Applicant, please complete: Please add your photo here FAMILY NAME: FIRST NAME: NATIONALITY: HOME UNIVERSITY: COUNTRY: FOR ESCR OFFICIAL USE ONLY ESC N Programme: Responsible Management Toefl/ Ielts / Toeic score: Date of reception Student as a fee-paying Payment: By cheque By bank transfer Early bird (before 1 April 20112 After 1 April 2012 Student as an exchange Signature International Studies Adviser: Accepted: Yes No Page 1 of 6
ONLY FULLY COMPLETED APPLICATION FORMS WILL BE CONSIDERED. PLEASE COMPLETE IN BLOCK CAPITAL LETTERS 1. PERSONAL INFORMATION TITLE: Mr Mrs Ms FAMILY NAME OR SURNAME: FIRST NAME(S) GENDER: Male Female POSTAL ADDRESS FOR CORRESPONDENCE N STREET: ZIP CODE: CITY: COUNTRY: TELEPHONE: (Country Code/Area Code/Telephone) MOBILE 'PHONE: (Country Code/Area Code/Telephone) E-MAIL 1: E-MAIL 2: Thank you to write your e-mail address very clearly so as to be able to contact you DATE OF BIRTH: / _/ _/ 19 (Day) (Month) (Year) CITY OF BIRTH: COUNTRY OF BIRTH: NATIONALITY: 2. EDUCATIONAL BACKGROUND 3.1. SENDING INSTITUTION (where you are registered today) Name of School / University Location (City, Country) Date of Entry (Month/Year) Expected date of Completion (Month/year) Name of Diploma or certificate prepared Please tick here if the programme was taught in English 3.2. POST-SECONDARY SCHOOLS AND UNIVERSITIES Name of School / University Location (City, Country) Date of Entry (Month/Year) Date of Completion (Month/year) Name of Diploma or certificate obtained Please tick here if the programme was taught in English Page 2 of 6
3.3. SKILLS Previous Business studies Yes No If yes, please give details Previous CSR studies Yes No If yes, please give details 3. EMPLOYMENT INFORMATION Please list all recent and relevant employment or internship experience: Employer Period Job Title (Name/City/Country) Responsibilities 4. LANGUAGE PROFICIENCY Please encircle the letter which best corresponds to your written and oral level in: Good working Native language Fluent knowledge Conversational Non-existent English A B C D E French A B C D E If you are a non native English speaker: Have you completed one of the following tests of English in the last 24 months? Yes No TOEFL (score ) IELTS (score ) TOEIC (score ) Other test: (score ) 5. INTERNATIONAL EXPERIENCE (if any) Year Length of Stay Country Reason Page 3 of 6
6. INTEREST AND MOTIVATION Please explain your interest and motivation in attending the summer programme Responsible Management. 7. MISCELLANEOUS Please tell us of any special circumstances we need to know about (e.g., physical handicaps, whether you will be bringing other family members with you, etc). 8. PERSON TO CONTACT IN CASE OF AN EMERGENCY Name: Address: Zip code: City: Country: Telephone: Mobile: Email: Page 4 of 6
9. APPLICATION PROCEDURE 1. Payment Fee-paying students Early bird fees, before 1 April 2012: 1 280 Fees after 1 April 2012 (no later than 15 April 2012): 1 450 The fees include tuition, accommodation, visits. Cultural visits could be organised at a small extra cost (Saint Malo, Vannes, Mont Saint Michel ) Exchange students The fees can be waived for students coming in the framework of an exchange agreement and as part of the incoming / outgoing ratio. Please refer to your home University Coordinator. In case of waived fees, the cost of transport, accommodation, living costs, cultural visits are to be met by the students. 2. Application deadline Early bird: 1 April 2012 Final deadline: 15 April 2012 10. PAYMENT DETAILS 1. Fees paid through: - Bank transfer in Euros to the bank account hereunder Proof of payment - Cheque payable in Euros to ESC Rennes School of Business Enclosed (The fees are payable in Euros) Name of Bank: Banque de Bretagne - 18 Quai Duguay Trouin - 35000 Rennes - France Bank Code: 40168 / Desk Code: 00019 / Account number: 1923 9202 284 Key 75 IBAN: FR76 4016 8000 1919 2492 0228 475 Code SWIFT: BDEBFR2R Payment Policy: This form (duly filled out; dated and signed) and the proof of payment must be sent back to ESC Rennes School of Business before 15 April 2011. ESC Rennes cannot be held responsible for transaction fees, foreign exchange losses and any additional charges, the cost of which must be borne by the candidate. Reimbursement Policy: If the student does not get his/her visa for reasons out of his/her control (written proof required), ESC Rennes will reimburse the tuition fees paid for the Responsible Manager summer programme. Dates of appointments at the Embassy are considered under the student s control. If the student decides to cancel his/her enrolment on the Responsible Manager summer programme, the fees are due and will not be refunded. I agree to the conditions above : Date:.. Signature:.. Page 5 of 6
11. HOME INSTITUTION AGREEMENT (mandatory for students on exchange) I authorise the student to participate in the Summer Programme 2012 Responsible Management - as part of our exchange agreement with ESC Rennes School of Business - France 1. Registration as an exchange student (Study Abroad Coordinator, International Relations Director, Programme Director, Academic Advisor, etc.) Name: University: Position Address: Zip code: City: Country: Telephone: Fax: Email: 2. Transfer of credit Please send the student s transcripts obtained at ESC Rennes to: The same address as above Other Name: Position: University name: Address: Zip code: City: Country: Telephone: Fax: Email: Date Signature: Official university stamp: ESC RENNES SCHOOL OF BUSINESS CS 76522, 2 rue Robert d Arbrissel, 35065 Rennes Cedex, France Telephone: (33) (0)2 99 54 63 63, Fax: (33) (0)2 99 33 08 24 Website: www.esc-rennes.fr ESC Rennes is committed to a policy of equal opportunity in student admissions without regard to race, colour, religion, sex, national origin, age, marital status or handicap. Page 6 of 6