Application Form for Visiting Student Internship Before completing this form, please refer to the application procedure for Visiting Students.

Please send this form to the Futures Centre (ucu.futures@uu.nl) before the internship starts.

When the Futures Centre has supplemented to this form, you can submit the form to the Registrar's Office (see last step).

Application Form for Visiting Student Internship

Before completing this form, please refer to the application procedure for Visiting Students.

Personal information

Full legal name (as it appears on your passport), use commas to separate your last and first name Former UCU Student ID number

1

Please provide a short description of the work, including the organization and contact details.

(Please remember that all the internship agreement forms need to be submitted as well before the start of the internship!)

I agree to the following:

- I will submit a reflection on my internship experience. This reflection will report on the

significance of the work for my personal development, my academic career, and on the role and importance of the organization I worked for in society

- I will make a contribution of €500,- to the scholarship fund as part of my internship agreement with the University College Utrecht. I will transfer the amount after receiving an invoice.

Signature of student Date

I am applying for academic year: 20 - 20 Effective dates of internship (dd/mm/yyyy):

Start End

Please submit this form to the Registrar's Office (ucu.registrar@uu.nl)

Important: In order to process you application, we need a photocopy of your passport.

Please include this with your visiting student form.

2

I agree to supervise the above-mentioned internship and understand that supervision means the following:

- I approve the internship plan described in this document - I will contact the Host Institution Supervisor if necessary

Signature of Coordinator Date

Coordinator Information

Name: E-mail: ucu.futures@uu.nl