1. Program choice:

One-year course: 1st semester 2nd semester
Summer courses: July 4 July 25
Duration: Intensity:

2. Type of accommodation required:

university dormitory
other (please specify)

3. Personal data:

Family name:

First name:

Date of birth: - - Sex: Male Female

Father`s (first) name:

Mother`s (first) name:


Passport No.:


Present employment:

Educational background (degrees, diplomas etc.):

4. Why do you want to study Polish?

5. Have you done any previous courses in Polish? If so, give details (e.g. titles of grammar books)

6. Rate your knowledge of the Polish language:

speaking: none poor fair good

reading: none poor fair good

writing: none poor fair good

7. Other foreign languages:

8. Do you suffer (or have a history of) any of the following conditions?

food or drug allergies asthma epilepsy mental disorders diabetes heart condition

Are you currently undergoing medical treatment? If so, give detalis

9. Name and address of a person in Poland to be notified in case of emergency:

10. Name and address of a person outside Poland to be notified in case of emergency:

11. For transfer of credits, supply complete address of your school`s Registrar:

12. Your address:

13. Email address: