UNIVERSITÀ DI PISA

SPACE ENGINEERING PROGRAM

GRADUATE ADMISSIONS – Academic Year 2013/14

ADMISSION APPLICATION

1 PERSONAL DATA

Last/Family Name       First Name       Middle Name      

Gender Male Female Date of Birth (DD/MM/YYYY)   /  /    
Birthplace (City)       State/Province       Country      
Country of Citizenship       Passport Number (or other valid document)      
Have you previously applied to graduate study here? Yes No If yes, what year?     

2 CONTACT INFORMATION

2.1 Current Mailing Address

Street (1)      

Street (2)      
City       State/Province       Postal Code      
Country      
Daytime Telephone Number       Fax      
Evening Telephone Number      
Email      
Current Mailing Address Valid Until (DD/MM/YYYY)   /  /    

2.2 Permanent Mailing Address

Street (1)      

Street (2)      
City       State/Province       Postal Code      
Country      
Daytime Telephone Number       Fax      
Evening Telephone Number      
Email      
Current Mailing Address Valid Until (DD/MM/YYYY)   /  /    
 UNIVERSITÀ DI PISA
SPACE ENGINEERING PROGRAM
GRADUATE ADMISSIONS – Academic Year 2013/14

3 EDUCATIONAL SUMMARY

List all colleges and universities attended, including those in which you are currently enrolled.

Institution Name Dates of Attendance (MM/YYYY)

(a)         /  /     –   /  /    
Degree Level Awarded/Expected Date (MM/YYYY) GPA
        /  /          

Institution Name Dates of Attendance (MM/YYYY)

(b)         /  /     –   /  /    
Degree Level Awarded/Expected Date (MM/YYYY) GPA
        /  /          

Institution Name Dates of Attendance (MM/YYYY)

(c)         /  /     –   /  /    
Degree Level Awarded/Expected Date (MM/YYYY) GPA
        /  /          

Institution Name Dates of Attendance (MM/YYYY)

(d)         /  /     –   /  /    
Degree Level Awarded/Expected Date (MM/YYYY) GPA
        /  /          

Institution Name Dates of Attendance (MM/YYYY)

(e)         /  /     –   /  /    
Degree Level Awarded/Expected Date (MM/YYYY) GPA
        /  /          

4 TEST SCORES

If you have taken graduate record examination tests, such as the GRE general test or GRE subject tests, please provide details
below

Test Type       Test Date (DD/MM/YYYY)   /  /     Score      

Test Type       Test Date (DD/MM/YYYY)   /  /     Score      

Test Type       Test Date (DD/MM/YYYY)   /  /     Score      

Test Type       Test Date (DD/MM/YYYY)   /  /     Score      

 UNIVERSITÀ DI PISA
SPACE ENGINEERING PROGRAM
GRADUATE ADMISSIONS – Academic Year 2013/14

5 LANGUAGE SKILLS

Describe your language skills using the following scale: 1 = Basic; 2 = Intermediate; 3 = Fluent; NL = Native Language

Language Reading Listening Speaking Writing

                 

                 

                 

                 

                 

If you have taken English language tests, such as TOEFL/TSE/TWE/IELTS, please provide details below

Test Type       Test Date (DD/MM/YYYY)   /  /     Score      

Test Type       Test Date (DD/MM/YYYY)   /  /     Score      

Test Type       Test Date (DD/MM/YYYY)   /  /     Score      

Test Type       Test Date (DD/MM/YYYY)   /  /     Score      

6 SCHOLARSHIPS / FELLOWSHIPS / HONORS / AWARDS

Please, specify which would be available to fund your future graduate study Applied for Received

     

     

     

     

7 Certification/and Authorization

I declare that the information on this form is true, correct, and complete. The University of Pisa has our permission to verify the
information reported by obtaining documentation as needed.

WARNING: Providing false information may result in University of Pisa revoking its initial decision to enroll the student.

STUDENT’S SIGNATURE: ________________________________________ DATE (DD/MM/YYYY): ___________________

 UNIVERSITÀ DI PISA
SPACE ENGINEERING PROGRAM
GRADUATE ADMISSIONS – Academic Year 2013/14

8 STATEMENT OF PURPOSE

Please use this page to express your statement of purpose (Do not exceed 3500 characters including blanks).

     
 UNIVERSITÀ DI PISA
SPACE ENGINEERING PROGRAM
GRADUATE ADMISSIONS – Academic Year 2013/14

9 ADDITIONAL INFORMATION

Please use this page for any additional information that was not captured within your application. If you feel you have already provided us
with sufficient information about yourself, you need not add anything here. (Do not exceed 3500 characters including blanks).