certified translation from polish

„Bionanomaterials - BioNaM: nowy kierunek interdyscyplinarnych studiów doktoranckich oraz program
staży dla studentów na I, II i III stopniu kształcenia”
CERTIFIED TRANSLATION FROM POLISH
Appendix No 1
to the “Regulations of Internships for undergraduate and postgraduate Master programme students of full-time
mode” in the framework of the Project ”Bionanomaterials - BioNaM: a new interdisciplinary field of Postgraduate
PhD studies and an internship programme for undergraduate, postgraduate Master programme and PhD
students”.
APPLICATION FORM
No Name
1 Project Name : Bionanomaterials - BioNaM: a new interdisciplinary field of Postgraduate PhD
studies and an internship programme for undergraduate, postgraduate Master programme and PhD
students”.
2 Project No : POKL.04.01.01-00-017/13
3 Priority IV: Higher education and science
4 Measure 4.1. Strengthening and development of didactic potential of universities and increasing the
number of graduates from faculties of key importance for knowledge-based economy.
5 Sub-measure 4.1.1. Strengthening and development of didactic potential of universities
PARTICULARS OF PROJECT PARTICIPANTS WHO ARE GRANTED EFS SUPPORT
No
1
2
Participant’ 3
s
4
personal
5
data
6
7
Contact
data
8
9
10
11
12
13
14
15
16
17
18
19
20
Additional
21
information
22
23
24
Name
First name ( middle name)
Family name
Sex
Age at joining the project
PESEL
Education
Care of children up to the age of 7 or
care of the dependent person
Street
Building No
Flat No
City
Area
Postal code
Region
County
Land telephone
Mobile phone
E-mail
Status of the participant on the labour
market at the moment he joins the
project
Type of the granted support
Project participation commencement
date
Project participation termination date*
Reason for the withdrawal from the
granted form of support (if applicable)
Disability
F
M
urban
rural
Professionally active
Not active
………………………………..
Place, date
……………………………………………….
Legible signature
*DO NOT FILL IN – Project participation termination date will be put down by the Project Office worker
when the suport is finished.
Projekt współfinansowa ny ze środków Unii Europejskiej w ramach Europejskiego Funduszu Społecznego
„Bionanomaterials - BioNaM: nowy kierunek interdyscyplinarnych studiów doktoranckich oraz program
staży dla studentów na I, II i III stopniu kształcenia”
Appendix No 1 to the Application Form constituting the Appendix No 1 to the „Regulations of Vocational
internships run by Wrocław University of Technology for the benefit of the Project “Bionanomaterials - BioNaM:
a new interdisciplinary field of Postgraduate PhD studies and an internship programme for undergraduate,
postgraduate Master programme and PhD students”.
DECLARATION OF THE PROJECT PARTICIPANT’S CONSENT
TO HAVE PERSONAL DATA PROCESSED
Having joined the Project: „Bionanomaterials - BioNaM: a new interdisciplinary field of Postgraduate
PhD studies and an internship programme for undergraduate, postgraduate Master programme and
PhD students” in the framework of the Human Capital Operational Programme, I hereby agree to
have my personal data processed .
I hereby acknowledge that:
1)
Ministerstwo Rozwoju Regionalnego [Ministry of Regional Development], at Wspólna 2/4, 00926 Warsaw, the institution managing the Human Capital Operational Programme, is the administrator
of my collected data.
2)
The legal basis for processing of my personal data is provided for in art. 23 section 1 point 2
or art. 27 section 2 point 2 of the act dated August 29th 1997 concerning personal data protection
(consolidated text : Dz. U. [Journal of Laws] of 2002. No 101 section 926, as amended) – personal
data is essential for the execution of the Human Capital Operational Programme,
3)
My personal data shall be processed exclusively for the purpose of support and execution of
the Project “ Bionanomaterials-BioNaM: a new interdisciplinary field of Postgraduate PhD studies and
an internship programme for undergraduate, postgraduate Master programme and PhD students”,
assessment, control , monitoring and reporting purposes within the Human Capital Operational
Programme (POKL).
4)
My personal date has been transferred for processing purposes to the Intermediate Body –
the National Centre for Research and Development, at Nowogrodzka 47A, 00-695 Warsaw, a
beneficiary which is doing the project for Politechnika Wrocławska [Wrocław University of
Technology], Wybrzeże Wyspiańskiego 27, 50-370 Wrocław and the parties, which upon the
beneficiary’s commission , participate in the project execution: Université Montpellier 2 Sciences et
Techniques, Place Eugène Bataillon – 34095, Cedex 5, Montpellier, France and Julius – Maximilians
- Universität – Würzburg, Sanderring 2, 97070 Würzburg, Germany. My personal date may be made
available to other research institutions doing assessment upon the commission of the POKL [Human
Capital Operational Programme] , Management Institute, Intermediate Body or the beneficiary or to
specialised entities which carry out monitoring activities upon the commission of the POKL,
Management Institute, Intermediate Body within POKL [Human Capital Operational Programme]
5)
Submission of data is voluntary, however the refusal to submit data is tantamount with the
refusal to grant the support in the framework of the Project;
6)
I have the right to have access to my data and the right to amend it
………………………………..
Place, date
……………………………………………….
Legible signature
Projekt współfinansowa ny ze środków Unii Europejskiej w ramach Europejskiego Funduszu Społecznego