INFORMATION SHEET
Typed by the school : ED 072 (ED SPI “Université Lille Nord – de – France”)
INE number (student national identification) (1) ______________________________
___
LAST NAME
Registered School for thesis :
CANDIDATE
Courtesy : Mr
Mrs
Miss
(2) - Spouse:- Usual first name:
- Insee number:
- Birthday:
- Place of birth:
- Region of birth:
- Country of birth :
- Nationality (2) : France
Other EU countries
- Other countries signed agreements with EU Higher education system
(3) - Other nationalities
Family situation : single
married
widower
divorced
concubine
separed
pacs
(2)- Date of the latest modification of famille situation (4) - Number of children:
Military service status: impertinent
accomplished
reformed
sursitaire
liberated
exempted
civil volunteer
undergoing
Incorporable
Dispensed
inaccomplished
(2) Type of military service : active
civil
technical aid volunteer
cooperation
Information volunteer
.conscientious objector
Volunteer
Civil volunteer (2) Beginning of military service :End of military service :
Personal address (number, street or avenue or boulevard) : - Postal code
- City
- Personal phone
- Professional phone (laboratory) - Email
Professional situation :
- Are you state officer : YES
NO
(2)- If YES are you intern
occupant
officer assistant
(2)In which domain : _ _ _ _ _ _ _ _ _ _ _ _ _ _ , place of work _ _ _ _ _ _ _ _ _
ACADEMIC BACKGROUND
Country of obtained degree : School of obtained degree : Category of degree : Date of graduation :
Are you occupant of the aggregation : YES NO (2) Are you former student of an ENS : YES NO (2) Rang of degree :
Degree's distinction : If master degree :
- Name of degree : Domain :
Distinction : Major :
- Master discipline (8) :
If DEA : (cf. doctorate degrees directory : http://dr.education.fr/dea.html)
Fiche élaborée par le bureau des allocations de recherche et du post-doctorat – Direction de la recherche –
Ministère de l'Education Nationale, Enseignement supérieur, Recherche mai 2008
- Code : _ _ _ _ _ _ _ _ ; Specification : If dispensation of DEA or Master :
- Year of dispensation : - If foreign degree : - Name of degree
If DEA or dispensation obtained previsously the application year, precise : - Motive of derogation :
If aggregation, specify : - Specification
- Year - Rang
If you are student of an ENS, specify which one
RESEARCH
(The sections to complete below are to verify by the school) School of research (5) :Thesis subject Thesis supervisor
-Courtesy : Mr
Mrs
Miss
(2) -First name-Last name
-Section CNU (6) : _________
-Are they member of Institut Universitaire de France (IUF) Principal disciplinary sector of the thesis (7) :
-If necessary, 1st secondary disciplinary sector of the thesis (7) : -If necessary, 2nd secondary disciplinary sector of the thesis (7) : Research unit :
If contractualized : Label and number of the laboratory (compulsory) : Specification :
If non contractualized,
-Research organism (specification) -Code of the laboratory
-Name of the laboratory
Localisation of laboratory (address, postal code, city) : If co-direction, precise :
Thesis co-supervisor
-Courtesy : Mr
Mrs
Miss
(2) -First name-Last name
-Section CNU (6) : _________
Research unit :
If contractualizes : Code of the laboratory (compulsory) : Specification :
If non contractualized,
-Research organism (specification) -Code of the laboratory
-Name of the laboratory
Localisation of laboratory (address, postal code, city) :
--- Compulsory information : can not be filled up without the presence of the person.
Check in the correspondant case.
Other than EU countries, this agreement was signed by the principality of Andorre, Bulgary, Croatia, The Federation of Russia, Island, Norway, Roumania, Switzerland, Turkey, Vatican.
Examples : date of marriage, divorce, ...
If the research takes place in a laboratory located in another school other than that of thesis registration.
Only for teacher-researchers ; cf. : http://dr.education.fr/Contrats/Nomenclature1.xls
This section is compulsory and must be correctly informed. The list of disciplinary sectors available for consultation on http://dr.education.fr/SIREDO/DS_RSD_SD.xls
This section is compulsory and must be correctly informed. The list of SISE sectors available for consultation on http://dr.education.fr/SIREDO/sd_sise.xls
Fiche élaborée par le bureau des allocations de recherche et du post-doctorat – Direction de la recherche –
Ministère de l'Education Nationale, Enseignement supérieur, Recherche mai 2008
