DECLARATION

LEGAL NAME (WRITE NAME EXACTLY AS IT APPEARS ON OFFICIAL DOCUMENTS)

FAMILY/SURNAME: _______________________________________________________
GIVEN/FIRST NAME: _______________________________________________________
PERMANENT HOME ADDRESS: _______________________________________________

DATE AND PLACE OF BIRTH(mm/dd/yyyy):________________________________________

Please, tick the appropriate box below:

I declare that I do not suffer from dyslexia.

I acknowledge that during my studies at the University of Szeged I am not entitled to

request any preferential treatment (time extension at oral or written examinations,
ignorance of spelling mistakes) with reference to diagnosed dyslexia or other learning
disabilities.

I declare that I suffer from dyslexia.

I declare that I suffer from other learning disabilities.

Please specify:__________________________________________________________
Medical documentation is attached.

CERTIFY THAT ALL THE ABOVE MENTIONED INFORMATION AND ANY OTHER SUPPORTING MATERIALSIS FACTUALLY TRUE, AND
HONESTLY PRESENTED, AND THAT THESE DOCUMENTS WILL BECOME THE PROPERTY OF THE INSTITUTION TO WHICH I AM APPLYING
AND WILL NOT BE RETURNED TO ME. I UNDERSTAND THAT I MAY BE SUBJECT TO DISCIPLINARY ACTION, SHOULD THE INFORMATION I
HAVE CERTIFIED BE FALSE.

STUDENTS SIGNATURE:PLACE AND DATE:.................

(MM/DD/YYYY)