Medical Sciences Faculty. Olsztyn. Application Form.

Please fill in all fields of the form, and make sure they are certain and correct.
(Please DO NOT use symbols like & # / \ { } etc. in all following fields.)

Program
(choose the appropriate)

6-months intense pre-medical program

April 2024 - September 2024

1-year pre-medical program

October 2024 - June 2025

Personal Data

Title (Mr/Ms/Miss/Mrs etc.)

Male Female

Surname

Family Name (if used)

First Name(s)

Father's First Name

Mother's First and Maiden Name

Date of birth (year/month/day in format yyyy/mm/dd)

Place of birth (Country, City)

Citizenship

Nationality (optionally)

Face Photo

Please prepare your photo in electronic version on this computer
or on the pen-drive you can already use.
The available file format: .jpg .jpeg .png .xpng
and preffered color photo 2:3 30x45mm
with maximum file size of 1MB.

Please select a photo file and preview result:

By sending the above photo file, you agree and give exclusive permission for Medical Sciences Faculty to use your photo in all parts of internal application, and future study activities, include personal identification and control.
At any time, you can request its deletion.

Passport Information

Passport Country

Passport Number

Date of Issue (year/month/day in format yyyy/mm/dd)

Date of Expiry (year/month/day in format yyyy/mm/dd)

Issuing Authority

Contact Information

Permanent Address

Correspondence Address (if different)

Street and No

City

Postal/Zip-code

Country

Telephone (please type only digits)

Mobile/cell phone numer,
(in int'l format +YY XXX XXXXXX...):

Stationary phone (optionally only)
Country Code / Area Code / Number:

E-mail (please type in both fields exactly the same string)

Language Proficiency Information
Please choose the appropriate

English is my first language

I attended a high school / promedical college in an English-speaking country prior to admission

English is not my first language (you need to submit proof of your proficiency in English)

Financial Support

How do you intend to finance your studies? (Personal savings, Private sponsor, etc., max. 100 characters)

Please give details of any loans or grants you are applying for, or have already secured. (optionally only, max. 100 characters)

Declaration

I consent to the collection and processing or relevant personal data by the University of Warmia and Mazury. I understand that
the information provided on this form will be held and used for the purpose of processing my application for study and for student administration. All information on this application and appended thereto is protected by the Polish data protection laws.

I certify that the information I have given on this application form is complete and accurate.

I agree to all the above

Sending date

Check all fields of this form before sending
If you want to keep a copy, please print it before sending
For further issues, please contact to: studyingmedicine@gmail.com

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		University of Warmia and Mazury School of Medicine. Olsztyn. Poland. Pre-med Application form
		Admission Office Address: University of Warmia and Mazury Faculty of Medical Sciences Warszawska Street 30 10-082 Olsztyn, Poland