This form should be returned with 2 passport-size pictures and a photocopy of the student's ID (both sides) to IECS Strasbourg, before March 1, 2007. 

Last Name: ______________________________First Name:___________________

Middle:______________________

Date of Birth: ____________________________ Gender:______________________

Permanent Home Address:______________________________________________

City/Town: ______________________________Country: ______________________

State: _____________________ Zip Code or Postal Code: _____________________

Home Telephone: _______________ E-mail address: _________________________

 Home University: ______________________________________________________

Year of Study: ____________________________

Major: ______________________________________________________________

Number of Semesters of French Language Instruction:_______________________

Smoker / Non-smoker: ________

Any additional information you might want to add:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

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IECS Strasbourg - Graduate School of Management - Universite Robert Schuman

61, avenue de la Forêt-Noire - 67085 Strasbourg Cedex - FRANCE