DEMANDE DE CONVENTION DE STAGE

Abroad
Academic year: 20_ _ / 20_ _

ASSIGNMENT FORM

Abroad

	Academic year: 20_ _ / 20_ _

Please return the present document duly completed and signed at the Careers and Internships Office or send it to convention-stage@icn-groupe.fr , with the “Infostage” document duly completed and signed and the insurance certificates.

STUDENT

Student’s full name, *Student’s name and surname*	Position : [ ] ICN1 Specify : [ ] Nancy [ ] Metz [ ] ICN2 [ ] ICN Gap Year [ ] ICN3 [ ] Magistratura [ ] Other : - Routes : - ARTEM Workshop :
Address : *Complete and permanent address*	Tel :
	E-mail : *Valid e-mail* *that is checked periodically*

Internship agreement request :
[ ] Yes

[ ] No (submit a copy of the bipartite employment contract or internship agreement, the _________________ “Infostage” document and the specific internship agreement at international level duly _________________ completed and signed)

ORGANIZATION

Organization :	Name, surname of the signatory representative :
Group (parent company) :	Job :
	Address :
Activity sector :	Post Code :
	Town :
Website:	Country :
	E-mail : Tel :
Place of internship	Supervisor in the workplace
Address :	Name, surname :
	Job :
Post Code :	Department / Office :
Town :	Tel : Fax :
Country :	E-mail :

PROJECT WORK MISSION

Title :

Start date :
End date :

Brief description of the Project Work:

Project Work objectives :

Evaluation criterion :

CONDITIONS OF PLACEMENT

Weekly maximum presence time at the working place : hours	Gross monthly compensation : euros / month
	Terms of payment : [ ] Transfer [ ] Cheque [ ] Cash
Special circumstances for the trainee’s presence at the workplace at night, on Sundays, on public holidays… : ------------- ---[ ] No [ ] Yes Specify :	Fringe benefits or benefits in kind :

TRAINEE’S COVERAGE

1) Health and Sickness coverage for placements abroad, provided by the organization :

[ ] YES (this coverage will complement rights and benefits provided by French Sécurité sociale ______________ coverage)
[ ] NO (the trainee will only be covered by the extension of existing French health and sickness cover ________________ abroad)

2) Insurance coverage for Accidents in the workplace for trainees abroad :

The organization undertakes to cover the trainee against risk of accident in the workplace, risk of accident on the way to and from the place of work and risk of occupational illnesses or disease, and to make all necessary notifications and declarations if :

        ▪ the compensation exceeds 12,5% of the ceiling of the French Sécurité sociale
- either for a statutory 35 hour working week : 436,05 €
- or for a statutory 39 hour working week: 488,85 €
        ▪ or the placement exceeds 12 months including all extensions
        ▪ or the placement doesn’t take place exclusively in the organization or the country designated in this assignment form

EXPERIENCE ABROAD (to be completed by ICN Gap Year and ICN 3 only)

[ ] I am planning to study in a partner University abroad during this academic year
[ ] I have already completed experience outside France: [ ] Work experience; [ ]University study; [ ] Other:

Company or University:
Country:

From:
To:

STUDENT’S COMMITMENT

● I have completed all the information above.
● I understand that this document will be demanded before signature of an internship agreement and before taking account of this _- experience within the end-of-study compulsory internship.
● I understand that this optional academic year does not necessarily lead to validation of the end-of-study compulsory internship.
● I agree to adhere to the terms of the internship agreement and agree not to request termination before the official end-date

ORGANIZATION	STUDENT	EDUCATIONAL TUTOR
Name, signature of the trainee’s supervisor and seal of the organization	Student’s signature	Educational tutor’s name and signature
Done at Date :	Done at Date :	Done at Date :

For further information, please contact the Careers and Internships Office by telephone at +33 (0)3 83 17 08 46, or by email at convention-stage@icn-groupe.fr .