IN WARSAW

Register No.
App. Reg. No.
Received on .................................................................
Payment date. .....................................................................
ACADEMIC YEAR 2014/2015
Amount................................................................................
His Magnificence the RECTOR
UNIVERSITY OF ECOLOGY AND MANAGEMENT (WSEiZ)
IN WARSAW
APPLICATION
I ask to be admitted to the full-time second-cycle studies
at the Faculty of Architecture,
major: Architecture,
.......…….....………………........……........
candidate's signature
I.
1.
2.
3.
LAST NAME
- 19
day - month - year
PESEL (Personal Identification
Number)
MOTHER'S NAME
5.
PERMANENT RESIDENCE ADDRESS
street:
10.
SURNAME AT BIRTH
(if married):
PROVINCE
COUNTRY
CITIZENSHIP
for foreigners of the Polish origin, check the
POLISH ORIGIN
village
building no.:
please check: town
postal code:
community:
province:
village
post office:
Stationary
phone:
Flat No.:
district:
building no.:
Town:
9.
please check: town
post office:
CONTACT ADDRESS
street:
7.
IDENTITY CARD SERIES AND NO.
SECOND NAME
FATHER'S NAME
Town:
8.
PLACE OF BIRTH
DATE OF BIRTH
4.
6.
CANDIDATE FACT FINDER
(please, fill in in block letters!)
FIRST NAME
Mobile phone
district:
Flat No.:
postal code:
community:
Work phone:
province:
e-mail (required field!)
PHONE
NUMBERS
MAIN SOURCE OF UPKEEP – information required by Ministry of Science and Higher Education (MNiSW)
Please, check the appropriate: agricultural: parents' dependant (farmers), own farm;
non-agricultural - what professions, parents' dependant, pension, survivor's pension, retirement pension, other (what)
............................................................................. .
PLACE OF EMPLOYMENT (name of the company):
Position
Town:
SECONDARY SCHOOL ATTENDED
Full name of the school:
Year of completion
town
province
11.
UNIVERSITY/COLLEGE ATTENDED
Full name of the school:
town
province
faculty
Major
speciality
University/college diploma No.
receiving degree of: Engineer*,
12.
of
engineer architect*,
master of science*
Possible level of disability (what):
light*
moderate*
heavy*
Additional information:
­ deaf or audibly impaired *
­ motor dysfunction – ambulant*
­ blind or visually impaired*
- motor dysfunction – non-ambulant*
- other type of disability*
INSTRUCTION FOR CANDIDATES
1.
The application and other documents provides to the University Management must be filled in readably and accurately.
2.
The candidate is hereby warned about criminal responsibility under Art. 233 of the Penal Code for giving false data.
* Check the appropriate
I attach the following documents to the application:
1.
HIGHER EDUCATION DIPLOMA - a copy
Authority issuing the diploma
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
Place of issuance
Date of issuance dd -mm- yyyy
Diploma No.
Town:
Country:
2.
CERTIFICATE OF MATRICULATION - a copy (for new matriculation, no data from the high school certificate should be provided)
Authority issuing the certificate
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
Place of issuance
Date of issuance dd -mm- yyyy
Certificate No.
Town:
Country:
3.
Copy of the high school certificate (for new matriculation)
4.
4 Photographs
5.
Payment certificate
6.
Copy of the identity card (or the passport for foreigners)
7.
Other
II. DECLARATION
I hereby declare that I consent for

announcing the course completion and examination ratings achieved by me during my study in the area of the University and on the WSEiZ website,
 publishing personal announcements concerning me in the area of the University,
 participation in surveys monitoring quality of education, including in particular, in surveys related to future of WSEiZ graduates.
I hereby give consent for my personal data and my image (photograph) to be processed by the University of Ecology and Management (WSEiZ) in Warsaw as
a data administrator, under the Data Protection Act of August 29th, 1997 (Journal of Law, of 2002, No. 101, item 926 with amendments.) for recruitment
purposes and recording the course of my study. This data will be revealed only to the individuals and entities authorised to receive it under the regulations of law.
We inform that you have right to review and correct your personal data.
I confirm the accuracy of the data I reveal in this application with my own signature.
.............................................................
town, date
................................................................................
candidate's signature
I give my consent to receive from University of Ecology and Management (WSEiZ) in Warsaw commercial information, including promotion materials
electronically to the e-mail address specified above (in accordance with the act of 18.07.2002 r. on Rendering Electronic Services (Journal of Law, No. 144, item
1204). I am aware that my consent may be withdrawn any time, what will result in removal of my data and e-mail address from the distribution list.
.............................................................
town, date
................................................................................
candidate's signature
Any decisions of University authorities and information connected with course of the study will be published on the www.wseiz.pl website and in the WSEiZ
building.
Confirmation in case of resignation from studies and/or taking back the documents by the candidate/student:
Warsaw, on ................................................, signature ............................................................