Accommodation Registration Student Dormitory "SKRZAT" for

Accommodation Registration
Student Dormitory "SKRZAT"
for student of ERASMUS+
Wniosek o zakwaterowanie w DS "SKRZAT"
dla studentów programu ERASMUS+
Family name / Nazwisko
Name(s) / Imię
Date of birth / Data urodzenia
Sex / Płeć
Nationality / Narodowość
Country / Kraj
Home address
Adres zamieszkania
ID number / Dowód. tożsamości
E-mail
Correspondence address
Adres do korespondencji
Special needs
(specjalne potrzeby)
Sending university
Uczelnia wysyłająca
Arrival date / Data przyjazdu
Departure date / Data wyjazdu
Bank account / Dane dot. rachunku bankowego:
Name of bank / Nazwa banku
IBAN / Nr rachunku
SWIFT Code / Kod SWIFT
I confirm that the information I have given in this form is true, complete and accurate and no information or other material information has
been omitted. I consent to the processing of my data by Jan Długosz University in Częstochowa for purposes of the recruitment process
and the documentation of my study at the JDU under the provisions of the Act of August 29, 1997 on the protection of personal data (unified
text: Journal of Laws of the 2002 No. 101 Item 926 with amendments).
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Date / Data
Signature / Podpis
Address (where to go) :
Dom Studencki "Skrzat"
ul. Dąbrowskiego 76/78, 42-200 Częstochowa
http://www.skrzat.ajd.czest.pl/