ENROLMENT FORM – SINGLE SUBJECTS

To the Rector
of the University of 
Modena and Reggio Emilia

I, the undersigned _________________________________________________________________
born in _______________________________________________ on ____/____/______________
resident in _______________________________________POSTCODE _________ at the address _____________ ________________ no. _____ mobile phone  __________________ email_______________________

•	with high-school diploma in_______________________________________________
obtained in ____________________________at the school ___________________________ 
                          (indicate the country where the diploma was obtained)                        (indicate the name of the school)	
City  ________________________________________________________________ 

in school year __________ / __________

•	with university degree in_______________________________________________
	             (Specify the type of Bachelor’s qualification: “General Bachelor”, “Bachelor of science”, etc.)

obtained in a.y. __________ / _________  at the University of ________________________
city ___________________________________ Country__________________________________
programme duration__________________ 

APPLY for the enrolment in the following single subjects (max 3 subjects):

□ Single subject in  ______________________________________________ No. credits (CFUs)_________
At the Department of __________________________________________________________
Degree Programme in ______________________________________________________________
□ Single subject in  ______________________________________________ No. credits (CFUs)_________
At the Department of __________________________________________________________
Degree Programme in ______________________________________________________________
□ Single subject in  ______________________________________________ No. credits (CFUs)_________
At the Department of __________________________________________________________
Degree Programme in ______________________________________________________________

Place and date
_________________________
(Signature)