Student
 	Last name(s)	First name(s)	Date of birth	Nationality	Sex [M/F]	Study cycle	Field of education 	

Sending Institution
	Name	Faculty/Department	Erasmus code  (if applicable)	Address	Country	Contact person name; email; phone	
							
Receiving Institution
 	Name	Faculty/ Department	Erasmus code (if applicable)	Address	Country	Contact person name; email; phone	

During the Mobility
 	Exceptional changes to Table A
(to be approved by e-mail or signature by the student, the responsible person in the Sending Institution and the responsible person in the Receiving Institution)	
Table A2
During the mobility	Component code 
(if any)	Component title at the Receiving Institution
(as indicated in the course catalogue) 	Deleted component
[tick if applicable]	Added component
[tick if applicable]	Reason for change	Number of ECTS  credits (or equivalent)	
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 	Exceptional changes to Table B (if applicable)
(to be approved by e-mail or signature by the student and the responsible person in the Sending Institution)	
Table B2
During the mobility	Component code 
(if any)	Component title at the Sending Institution
(as indicated in the course catalogue) 	Deleted component
[tick if applicable]	Added component
[tick if applicable]	
Number of ECTS credits (or equivalent)	
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Commitment	Name	Email	Position	Date	Signature	
Student	
					
Responsible person at the Sending Institution						
Responsible person at the Receiving Institution