coordenação central

Foto 3x4
(Fundo branco)
 Attach a
passport-style
photo here
Picture 3x4
(White background)
F O R M U L Á R I O
D E
R E G I S T R O
E S T U D A N T E S
(
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the
FORMULÁRIO DECheck
INSCRIÇÃO
NOME:
ex: Jane Lee Smith
(NAME – as written in the passport)
Data de Nasc. (Date of birth DD/MM/YYYY): _____
appropriate
box 
Sexo: Masculino Feminino
(Gender)
(Male)
(Female)
ex: 29/04/1991_______ Nacionalidade (Nationality): ____ ex: USA _____________
ex: Boston
Naturalidade (City of birth):
INFORMAÇÕES DO PROGRAMA (PROGRAM’S INFORMATION)
Nome do programa (Progam’s name):_ Boston University Rio de Janeiro Intensive Portuguese Language Program _
Instituição de origem (Home institution): ________ your home university__________________________________________________
Coordenação Acadêmica (Academic Coordination): ________ Professor Celia Bianconi, Boston University __________________
Data de Início (Start date): _______ 21 June 2015___________ Data de Término (End date): _________31 July 2015____________
DADOS PESSOAIS: (preenchimento obrigatório)
(PERSONAL RECORDS: (Mandatory))
Endereço (Address):
Use your home address
phone number for this section
Cidade and
(City):
CEP (Zip Code):
Bairro (District):
Telefone (Phone #):
Celular (Cellphone #):
Identidade (ID):
Leave this section blank
Órgão Exp. (Emitted by):
Fax:
( ) próprio (self)
( ) responsável (guardian)
CPF (Security #):
Nº Passaporte (Passport #):_____________________________________________________________________________________________
Fill this section out with your passport information
Data de Expedição (Issue date DD/MM/YYYY):
Estado Civil (Marital Status):
E-mail:
E-mail:
Data de Expiração (Expiration Date DD/MM/YYYY):
single
use your email address
DADOS ACADÊMICOS: (preenchimento obrigatório)
Circle
“Graduação”
(
) Mestrado (Masters) (
) MBA (
(ACADEMIC DATA: (Mandatory))
) Doutorado (Doctorate)
Graduação/ pós-graduação (Undergrad./grad.): _____ your home university _______________________________________________
CR (acumulado) (GPA):_ex:3.0_ Período de créditos (Year/ term):_Summer 2015_ Formatura prevista em (Expected to graduate in): ex: May 2016
Bolsa de estudos? (Scholarship?) (
) Sim (Yes) ________% (
if you
any scholarships for this program
) Não (No) Tipo
deIndicate
Bolsa (What
kind?)receive
:_____________________________________
CONHECIMENTO DE LÍNGUA ESTRANGEIRA (FOREIGN LANGUAGE KNOWLEDGE):
Alemão(German): Nível (Level): ( ) Nenhum (None) ( ) Básico (Basic) ( ) Intermed. (Intermediate) ( ) Avançado (Advanced) ( ) Nativo (Native)
Fill out this
Espanhol(Spanish): Nível (Level): ( ) Nenhum (None) ( ) Básico 
(Basic) ( ) Intermed. (Intermediate) ( ) Avançado (Advanced) ( ) Nativo (Native)
based on
Francês(French): Nível (Level): ( ) Nenhum (None) ( ) Básicosection
(Basic) ( ) Intermed. (Intermediate) ( ) Avançado (Advanced) ( ) Nativo (Native)
your
proficiency
Inglês(English):
Nível (Level): ( ) Nenhum (None) ( ) Básico (Basic) ( ) Intermed. (Intermediate) ( ) Avançado (Advanced) ( ) Nativo (Native)
in these languages
Italiano(Italian):
Nível (Level): ( ) Nenhum (None) ( ) Básico (Basic) ( ) Intermed. (Intermediate) ( ) Avançado (Advanced) ( ) Nativo (Native)
Outros (Other):___________________________________________________________________________________________
Rua Marquês de São Vicente, 225
Ed. Pe. Leonel Franca, 8º andar
CEP 22.453-900 – Rio de Janeiro – RJ – Brasil
Tel: (55-21) 3527-1577 / Fax: 3527-1094
http://www.puc-rio.br/ccci/ E-mail: [email protected]
FILIAÇÃO: (preenchimento obrigatório)
(PARENTAL INFORMATION, mandatory)
Nome do pai (Father’s name): ___________________________________________________________________________________________
Profissão (Profession): _________________________________________________________________________________________________
Endereço (Address): __________________________________________________________________________________________________
Bairro (District): __________________________________________________________________ Cep (Zip code):________________________
Telefone (Phone #): ___________________________________________ Celular (Cellphone #):________________________________________
Nome da mãe (Mother’s name): __________________________________________________________________________________________
Profissão (Profession):__________________________________________________________________________________________________
Endereço (Address): ___________________________________________________________________________________________________
Bairro (District): _________________________________________________________________ Cep (Zip code): _________________________
Fill out these sections
as completely as
Telefone (Phone #): ___________________________________________ Celular (Cellphone #): ________________________________________
possible
Irmãos? (Siblings?) ( ) Sim, quantos? (Yes, how many?) __________
( ) Não (No)
Em caso de emergência, por favor, entrar em contato com: (preenchimento obrigatório) (In case of emergency, please contact: (Mandatory))
( ) Pai (Father) ( ) Mãe (Mother)
( ) Outros (Nome e Parentesco) (Others (Name and Family relation)):__________________________________________________________________
Telefone (Phone #): ___________________________________________ Celular (Cellphone #): _________________________________________
E-mail:_____________________________________________________________________________________________________________
Endereço (Address):____________________________________________________________________________________________________
Bairro (District): _______________________________________________ Cidade (City): _____________________________________________
Estado (State): __________________________________________________ Cep
(Zip Code):
_________________________________________
DADOS PROFISSIONAIS (em ordem decrescente) (PROFESSIONAL RECORDS (from your last job to the previous ones)):
Trabalha?
(Do you work?)
(
) Sim (Yes) (
Profissão e cargo (Profession
and position):
) Não (No)
___________________________________________________________________________________
__________________________________________________________________________________________________________________
Empresa (Company): ___________________________________________________________________________________________________
( ) Integral (Full time)
( ) Meio expediente (Part time)
( ) Estágio (Internship)
Outro (Other):________________________________________________________________________________________________________
Profissão e cargo (Profession
and position):
___________________________________________________________________________________
__________________________________________________________________________________________________________________
Empresa (Company): ___________________________________________________________________________________________________
( ) Integral (Full time)
( ) Meio expediente (Part time)
( )these
Estágio
(Internship)
Leave
sections
blank –
this information is not required
Outro (Other):________________________________________________________________________________________________________
Profissão e cargo (Profession
and position):
___________________________________________________________________________________
__________________________________________________________________________________________________________________
Empresa (Company): ___________________________________________________________________________________________________
( ) Integral (Full time)
( ) Meio expediente (Part time)
( ) Estágio (Internship)
Outro (Other):________________________________________________________________________________________________________
Outras informações (resposta livre) (Other information ):
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Estou ciente das normas, direitos e deveres que regem os programas de intercâmbio de curta duração.
Declaro, ainda, que as informações acima são verdadeiras, corretas e atualizadas.
(I am aware of the terms and condition that are established by the short-term exchange programs. Also declare that the information above is legit, correct and updated.)
Em (At) _____ / _____ / _____
 Remember:
Don’t forget to
dd/mm/yyyy
sign and______________________________________________________________________
date 
Assinatura do candidato (Candidate’s signature)