THE MEDICAL UNIVERSITY OF WARSAW APPLICATION e-mail: english@akamed.waw.pl

 
APPLICATION

             I wish to enrol as a student of the 2nd  Faculty of Medicine at the Medical University of Warsaw, into the English speaking programme for foreign students. I agree to abide by the curriculum regulations and  to make the necessary regular payments of the university fees.
 

Date .......................                             Signature ...................................

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                                           QUESTIONNAIRE                    YEAR 2000/01

1. Family name ..................................    First names ...............................................
    maiden name..................................                          Sex*: F. o - M. o

2. Date of birth ...................... year,........................ month, ............................. day
   Place of birth ............................................... country.............................................

3. Citizenship ..................................... nationality ....................................................
4. Permanent address .............................................................................................
    .................................................................... country ..............................................

5. Correspondence  address .................................................................................
................................................................... country....................................................
home tel: ..............................

6. Knowledge of languages:
a) Polish    speaking o     good  o     average  o  none o
                   writing      o     good  o     average  o  none o
b) English  very good  o   good  o
c) other........................................    very good  o    good   o   average   o
d) .................................................    very good  o    good   o   average   o

* Please cross the ring ( o ) if applicable. F-female, M.-male

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QUESTIONNAIRE  page  2

7. Marital status: single............... married ................. children ...................

8. Parents’(or guardians) data: names, dates of birth, addresses:

a) father.........................................................................................................

b) mother..........................................................................................................

Profession, occupation, employment address tel./fax:......................................

a) father.........................................................................................................

b) mother.......................................................................................................

9. Education:

a) secondary school .........................................................................................
                                    name of school    place       date from-to  certificate

b) higher/courses .............................................................................................
                               university.................    place        date from-to  certificate

10. Recent occupation, employment, location (if any).....................................

11. Family in Poland, name of relative, address:............................................
      ........................................................................................................................
12. Who is going to pay the University fee:candidate (loan?)  o
      parents/guardians (see paragraph 8)  o    other sources   o

13. Other information essential for recruitment:..............................................
      .......................................................................................................................
14. Declaration of parents/guardians:

I / We accept and undertake the financial commitments of the applicant, my son/daughter.
 
Place .................................      Date ......................... Signature ........................
 
   Family and first names (printed), relationship to applicant, work and home
   tel./fax:.............................................................................................

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