ENROLLMENT FORM

PERSONAL DATA

First Name

Middle Name

Last Name

Mother’s First Name

Father’s First Name

Date of Birth: DayMonthYear

Place of Birth

Citizenship

Passport Number

CURRENT ADDRESS

Street Name

Home Number

Apartment Number

Area Code

City

Country

MAILING ADDRESS (if different from above)

Street Name

Home Number

Apartment Number

Area Code

City

Country

CONTACT

Stationary Phone Number

Mobile

E-mail

CHOSEN DEPARTMENT

DEPARTMENTS

PAYMENT OPTION

Payee

Form of Payment

HIGH SCHOOL

School’s Name

School’s Location

Year of Graduation

I hereby authorize Mr./ Mrs with ID card number to receive any information about the course of study, to collect my documents, and to sign an annex to terminate the contract.

I hereby confirm the correctness of given data and agree for processing of my personal information by the Dziewulscy International College in accordance with the Personal Data Protection Act. I acknowledge that the payments made are not refundable in any case.