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Medical University of Warsaw

Dorm Requst Form
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Dorm Requst Form

This is a form you need to complete and send to the Dean's Department inorder to get a place in the dormitory. Just copy and paste it then print it. The regulations of the dorms are also found in the links to the left.

  
Surname           ………………………………


First name        ………………………………

Date of birth     ………………………………

Citizenship        ……………………………..

Student of         ………………………. . year





APPLICATION




I apply with a request to be allotted a place in the Students’ House in a single / double room*

for a period from …………………….  to ………………………….

Enclosed, please, find a copy of a confirmation of payment of ………………………………..


I declare that I am familiar with the Rules for the allotment of places in the Students’ House. Simultaneously, I pledge to observe the Rules of Residence in the Students’ House enclosed under separate cover.


In case I am not allotted a place in the Students’ House, please, refund the amount to the following account:

Name of the bank         …………………………………………………

Address                       ………………………………………………….

Account No                 ……………………………………………….....

Swift code                    ………………………………………………….




……………………………                                     ……………………………………

Place and date                                         Legible signature of the Student




* cross out if not applicable





Last Updated: 04/02/08