TEMPLATE FORM OF WITHDRAWAL FROM THE AGREEMENT

(the form should be completed and returned only if you wish to withdraw from the Agreement)

Recipient
(full name of the University and address)

I, the undersigned
(forename and surname)

PESEL
number
in the absence of a PESEL number, name of the identity document: passport

Passport
number

Name of the country that issued the passport …………………………

country of residence
City/Town
Postal code
Street
Apartment/house no.
e-mail address:

hereby declare that I withdraw from the Agreement for the provision of educational services

at
(full name of the University)

concluded on
(DD/MM/YYYY)

regarding studies:

Level of education (cycle) and type of studies *: Field of study and specialty, if applicable

 First-cycle studies
 Second-cycle studies
 Second-cycle studies with postgraduate …
programmes
 Long-cycle (Master’s) studies
 Postgraduate programme
 MBA studies

(date and legible signature)

*delete as appropriate