STUDENT APPLICATION FORM for Student Exchange Program
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Family Name
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Given Name
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Address for correspondence
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Telephone number
Telexfax number Email address
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Nationality
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Age Sex
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Qualifications (give details)
TECHNICAL
LEGAL
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Preferred Working Language:
Standard of that language
ORAL: very good good poor
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(please tick whichever is appropriate)
WRITTEN: very good good poor
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Current Employment Details
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Employment history
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Result of SEAD Course:
Distinction Credit Pass
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(please tick whichever is appropriate)
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Previous Patent Courses attended
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Knowledge of Patent Law and how obtained (including length of time exposed to patents)
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Preferred Country or Countries
1. ..........................................
2. ..........................................
3. ..........................................
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Preferred City or Cities
A.................................B..........................
A.................................B..........................
A.................................B..........................
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Why placement would be of value to? you
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Name and Address of Sponsor (that is of the person responsible for payment of registration fees)
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SIGNED ........................................................DATED..................
Please return this form to:
Mr. Francis Ahner
President
Training and Education Commission (FICPI)
c/o Cabinet Regimbeau
20, rue de Chazelles
75847 Paris, Cedex 17
France
Telephone: +33-1-4429 3500
Facsimile: +33-1-4429 3599
Email: ahner@regimbeau.fr
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