The Amsterdam - Maastricht University

Creating Multimedia Activities for Language Learning (lang 4)

Personal details:
Mr / Ms / Mrs:	Mr. Ms. Mrs.
Title:
First name:
Last name:
Address:
Postal code:
City:
State:
Country:
Is this address also your billing address?	Yes No
	Billing address: Company Name: Mr / Ms / Mrs: Mr. Ms. Mrs. Title: First name: Last name: Address: Postal code: City: State: Country:
Email:
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Fax (County Code, Regional Code, Number):
Date of Birth (please use the format DD/MM/YYYY):
Place of Birth:
Nationality:
Passport Number:
Passport Expiration Date (dd/mm/yyyy):
Qualifications & Skills:
Profession & Qualifications Please give a detailed description of your current profession and/or position, past ones (including duration of appointment) as well as of your educational qualifications. You may send in additional sheets or attach a CV:
Include copies of any relevant certificate or documentation in your application or pre-registration:
Computer Skills Please give a detailed description of your computer skills:
English Language Skills Please give a detailed description of your english language skills.:
	I have read, understand and agree with the applicable terms and conditions
	I will be medically insured during the period that I attend the AMSU course
	I would like to stay informed about AMSU courses and activities