FCJ-grant Student Application Form (aanvraagformulier voor een FCJ-beurs) Signature internship coordinator:

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1 Personal data Name and surname Student ID number Male/female Date of birth address Telephone number (during internship) Sofi number Bank/giro account(number) Name of bank and bank address FCJ-grant Student Application Form (aanvraagformulier voor een FCJ-beurs) Study data Study course Internship in which year? How many ECTS? Name of your internship mentor/coordinator at the FCJ Approval of the internship by of your internship mentor/coordinator at the FCJ Signature internship coordinator: Date: Internship data Company name Address Post code and city Country Contact person at the company Phone number address Starting date of internship End date of internship Duration in weeks Description of the internship (tasks, responsibilities, etc.) Mr/Mrs.

2 Insurance data Health Insurance Accident & Return Transport Insurance Personal Liability Insurance Travel Insurance via Hogeschool Utrecht Name of company Policy number Financial data Income Home grant (Groningen) (dit is de beurs; niet lening) Amount in, per. Total in entire period in proof, requested and attached Copy toelage IB groep Lening van Groningen ( ) ( ) Copy toelage IB groep O.V. vergoeding Copy toelage IB groep Salary from internship company Letter of appointment or contract (signed and stamped) Payment in kind from internship company (housing, meals, travelling expenses, visa,..) Other forms of income (grants, gifts, rent received for onderhuur kamer) TOTAL (excl. lening van Groningen ) Letter of appointment or contract (signed and stamped) Housing situation in The Netherlands (prior to your internship): Living at home (with parents); Living on my own at (complete address). During my placement abroad: I have no rental costs in The Netherlands; I have rental costs in The Netherlands of per month, total My room/apartment is being rented by a third party for per month, total income for me

3 Expenses Description Amount in, per. Total entire period in proof, available and/or attached Outbound travel N.A. E.g.: Booking confirmation/ticket/ Return travel N.A. Rent Subsistence (food, travel to/from work) Insurance (additional taken solely because of your stay abroad) Preparation expenses (language course) Official documents (visa) Vaccinations Other costs incurred TOTAL I herewith declare that: This form has been filled out completely and truthfully. I am aware that all payments of the FCJ grant are payments in advance and that when a form concerning the FCJ grant is found to contain false or incomplete information, the grant awarding authority, which provided me with a grant, has the right to claim reimbursement for the FCJ grant.. I am aware that in case of finishing the internship prior to official end date, the grant awarding authority, which provided me with a grant, has the right to claim reimbursement for the FCJ grant. I was informed about the necessity of an adequate insurance protection and I will take care of a sufficient insurance protection during my placement abroad. I have not previously received an FCJ grant. I will send all requested forms and documents to the grant awarding authority within 2 weeks after my placement has ended. Place and date:... Name: Signature:...

4 Letter of appointment (to be filled out by your company supervisor) I, the undersigned, herewith declare that (name student), will undertake an internship at our organization: Company name: Address Post code and city: Country: Starting date of the internship: End date of the internship: Compensation: The student will receive a gross/net salary of per week/month The company will pay for the student rent visa expenses in- and or outbound travelling expenses other expenses, for the amount of (per ). Name: Function: Date and Place; Signature and stamp:

5 This part should be completed and included with the application, as a condition for actual payment Details for payment (to be filled out by the applicant) Name student: Sofi: Bank/giro account number Bank address ====================================================== To be filled out by grant awarding authority Total Income Total Expenses Income -/- expenses Toegekende FCJ Grant (Max. 750,=) Uit te betalen: Betaalwijze: Volledig bedrag in één keer Voorschot ( %, ) en restant ( ) na afronding van de stage met minimaal een voldoende (door docentbegeleider) / aanleveren van: Te boeken op Activiteit xxx Naam: Handtekening: Datum: ===================================================================== To be filled out by grant awarding authority Voor akkoord getekend door Budgethouder, datum, Naam, Handtekening