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    date of receipt
University Centre for Language Education University of Zielona Góra	
APPLICATION FORM
 FOR A FOREIGN LANGUAGE COURSE
Personal data of course participant: 
	
Surname: ………………………. 			Names: ………………………		……………………..
Date of birth: …………… 				Place of birth: ………………….
Permanent address: 
code: ……………….			place: ………………	         post office: …………………………
str. …………………. 			house/apartment no. ………….... voivodeship: …………….........
phone: ……………………          		e-mail: ……………………

Please tick the appropriate box. 

•	The course participant is an adult 			The course participant is a minor 

•	I choose the following language course:	English 		 German 	Spanish	 Russian  French 		Italian 				          

•	I choose the following level:  A0 (for beginners)  A1  A2  B1  B2  C1  C2    

•	I choose the following course: standard 60-hour                   
•	preparation for the school leaving (matura) exam     
  
•	I am: a UZ employee 				a family member of a UZ employee* 	                        student/PhD student at UZ  	 	                          a student from outside UZ  
* Family members: spouse/ child/ grandchild 

•	I found out about UCKJ UZ language courses:
from friends    from the internet     from facebook     from advertising in the city 	       from media advertising 	

 I am continuing my course at UCKJ UZ

 other (specify) …………………………………………………………………………………………………………..…

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

Surname: ................................................................................................     Name ...................................................... 
Permanent residence address: 
postal code:.................................. town:........................................................ post office .........................................................
str. ............................................................ house/apartment no. ..............      voivodeship: ............................................ 	
telephone number of legal guardian …................................................ 	e-mail …………………………………………
Correspondence address (please fill in if different than above): 
code:................................. town:.................................................... post office: ....................................................
str. ......................................................... house/apartment no. .............. voivodeship: ................................................

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