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

 
  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 2018 - September 2018
1-year pre-medical program
October 2017 - June 2018
 
 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
 Street and No
 City
 City
 Postal/Zip-code
 Postal/Zip-code
 Country
 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

 

 To send this application form:
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 ONLY ONE TIME
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 continue on this web page.

 
 

Copyright ©2010-2017 University of Warmia and Mazury. Poland. Olsztyn. Medical Sciences Faculty.