Acommodation Form

ACCOMMODATION APPLICATION FORM
“AKADEMIK VIKTORIA”
The International Relations Office of the PWSTE in Jaroslaw would like to offer the dormitory
places for international students in our hall of residence – “Victoria”. The monthly cost of that place is:
□ single room (regular or high standard) – 300 PLN - 336 PLN ( 70 EUR – 78 EUR)
□ double room (regular or high standard) – 280 PLN – 312 PLN (65 EUR – 72 EUR)
□ room for three (regular or high standard) – 260 PLN – 288 PLN - ( 60 EUR – 66 EUR)
□ room for four (regular) – 240 PLN – 264 PLN (55 EUR – 61 EUR)
(please mark the selected box)
PLEASE FILL OUT ALL DATA LEGIBLY IN CAPITAL LETTERS
1. Family name
2. First name
3.
Sex (F/M)
Correspondence address:
4. Postal code
5.
City
6. Street
7. Number
8. Country
9. Phone No.
10. E-mail address
Period of stay:
from (______/______/______) to (______/______/______)
Arrival date:________________________
______________________
__________________________
Student’s signature
Date
The complete application form must be send to e-mail address:
[email protected]