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    date of receipt
University Centre for Language Education University of Zielona Góra	

DECLARATION OF PARTICIPATION

 IN A FREE JAPANESE LANGUAGE COURSE

Personal data of course participant: 
	
Surname: ………………………….. 			  Name: ………………………………………..... Date of birth: ……………………. Place of birth:…………………………… Address:
Code:……… Town/City:………………………….      Street:………………………………………….
 						    house/apartment number:……….
Phone: ……………………          				e-mail: …………………………………………

Please check the appropriate box. 

•	I choose the beginner level			     
•	I choose the intermediate level		
•	I choose the advanced level   			   
•	I am:    
o	a UZ employee 			
o	a UZ student/PhD student 		 
o	a student from outside UZ 		 

In the case of a minor course participant, details of the parent or legal guardian: 

Surname: ................................................................................................     Name ...................................................... 	
telephone number of legal guardian …................................................ 	e-mail …………………………………………

I consent to the processing of my personal data contained in the application form by the University of Zielona Góra, 65-417 Zielona Góra, ul. Licealna 9; phone 683282000, fax: 683270735, in order to conduct the current recruitment procedure for the language course. I provide my personal data voluntarily and declare that they are true. At the same time, I declare that I have read the content of the information clause, including information about the purpose and methods of processing personal data and the right to access the content of my data and the right to correct it.

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Signature of course participant