ERASMUS+ STUDENT APPLICATION FORM

STUDENT MOBILITY FOR STUDIES

zdjęcie/photo
ERASMUS CODE: PL WARSZAW63

WYPEŁNIĆ DRUKOWANYMI LITERAMI! / FILL IN WITH BLOCK LETTERS!

Początek formularza
Nazwisko / Surname *

Imię/Imiona / First names *

PESEL / ID *

Płeć / Gender * Obywatelstwo / Citizenship

⸋Kobieta/Female ⸋Polskie/Polish
⸋ Mężczyzna/Male ⸋Inne/Other:…………………………………..……
Data urodzenia / Date of birth* DD.MM.YYYY: Miejsce urodzenia / Place of birth *:

Student ID no: E-mail:

Kierunek studiów / Field of Study * Nr Tel./ Phone no:

Aktualny rok studiów i semestr: Poziom studiów / Degree

Current study year and semester no:
⸋ Licencjackie/Bachelor
⸋ Magisterskie/Master
Średnia ocen z całego toku studiów: Preferowany czas pobytu / Preferred duration of stay
Average of grades from the whole period of study:
⸋ Jeden semestr/One semester
⸋ Rok/One year
ADRES ZAMELDOWANIA (Z DOWODU OSOBISTEGO) / PERMANENT ADDRESS (FROM YOUR PASSPORT/ID CARD):

Ulica / Street *

Numer domu / Number *

Kod pocztowy / Postal code *

Miejscowość / City *

Kraj / Country *
ADRES ZAMIESZKANIA/ CORRESPONDENCE ADDRESS:
Należy podać najczęściej używany! Please specify the most frequently used!

Ulica / Street *

Numer domu / Number *

Kod pocztowy / Postal code *

Miejscowość / City *

Kraj / Country *

Czy uczestniczyłeś/aś już w programie Erasmus podczas aktualnego toku studiów

Have you already participated in the Erasmus programme during the current course of study?

⸋ Tak/Yes [ile miesięcy trwała mobilność/ length of mobility in months:……………………………

⸋ Nie/No
Czy w nadchodzącym semestrze będziesz pobierać stypendium socjalne na AEH? *
Will you be receiving the social scholarship from the University of Economics and Human Sciences in Warsaw during the
approaching semester?

⸋Tak/ Yes ⸋ Nie/ No

Czy posiadasz orzeczony stopień niepełnosprawności? *
Do you have a certified degree of disability?

⸋ Tak/ Yes ⸋ Nie/ No

Czy posiadasz orzeczony stopień niepełnosprawności? *
Do you have a certified degree of disability?

⸋ Tak/ Yes ⸋ Nie/ No

Język w którym zamierzasz studiować na uczelni zagranicznej.
The language in which you want to study at a partner university
Należy podać jeden główny język wykładowy / Choose one

Kraj, do którego zamierzasz wyjechać w ramach programu Erasmus+:

The country to which you are planning to go under the Erasmus+ Program:

Czy wybrałeś/łaś już uczelnię, do której chciałbyś pojechać w ramach programu Erasmus+?
Have you already chosen a specific university you would like to go for Erasmus+?

⸋ Tak/Yes (nazwa preferowanej uczelni/ name of your preferred University:

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

⸋ Nie/No
“Wyrażam zgodę na przetwarzanie moich danych osobowych dla potrzeb niezbędnych do realizacji procesu kwalifikacji i
prawidłowej organizacji mobilności w projekcie Erasmus Mobilność Edukacyjna (KA103). Przyjmuję do wiadomości, iż
administratorem danych osobowych jest Akademia Ekonomiczno-Humanistyczna w Warszawie (ul. Okopowa 59, 01-043
Warszawa). Posiadam wiedzę, że podanie danych jest dobrowolne, jednak konieczne do realizacji celów, w jakim zostały
zebrane".

„I consent to the processing of my personal data for the purposes of the qualification process and the correct
organization of mobility in the Erasmus Educational Mobility project (KA103). I acknowledge that the administrator of
personal data is the University of Economics and Human Sciences in Warsaw (ul. Okopowa 59, 01-043 Warsaw). I have
knowledge that providing data is voluntary, but necessary to achieve the purposes for which it was collected”

……………………………
Miejscowość/City

…………………
data/date

……………………………………
podpis/signature

Załączniki/ Attachments

 1 zdjęcie/ 1 photo

 List rekomendacyjny od wykładowcy, lub opinia opiekuna specjalności wybranej przez studenta /
Letter of recommendation from the lecturer, or opinion of the tutor of the specialty chosen by the student

 Certyfikat językowy lub zaświadczenie od lektora/ Language certificate or certificate from the teacher

 Potwierdzenie średniej ocen z całego okresu studiów (zaświadczenie z Dziekanatu)/ Confirmation of the average
grade from the entire period of study (certificate from the Dean's Office)
 INFORMATION CLAUSE

Since May 25, 2018 provisions of Regulation (EU) 2016/679 of the European Parliament and of the Council of 27
April 2016 on the protection of individuals with regard to the processing of personal data and on the free movement of
such data and repealing Directive 95/46 / EC (general regulation on data protection - hereinafter “the Regulation”) have
been applying, therefore in accordance with the wording of art. 13 sec. 1 and sec. 2 of the Regulation, we would like to
provide you with some information:

Who is the administrator of personal data?

The administrator of your data will be University of Economics and Human Sciences (“AEH”) in Warsaw (01-043)
at 59 Okopowa Street, e- mail: zgloszenia@vizja.pl.

What is the purpose and legal basis for the processing of personal data?
Your personal data will be processed only to the extent and for the purpose necessary
to carry out the recruitment process, as part of the Erasmus+ Program run by the University
of Economics and Human Sciences in Warsaw, co-financed by the European Union.

Do you need to provide us with your personal data?

Providing personal data is voluntary, but necessary to participate in the recruitment process.

What are the categories of recipients?

The expected categories of recipients of your data are employees of the department
of European projects authorized by the Data Administrator and other persons authorized under the law.

What are your rights?

You have the right to access your data and the right to obtain a copy of your data, the right to correct it, remove it,
request processing restrictions, object to processing, and the right to transfer data and withdraw this consent at any time.
The consent may be withdrawn in a written or electronic form sent to the Data Administrator.

Can you file a complaint in terms of the processing of your data and where?
You have the right to file a complaint regarding the processing of data to the Supervisory Authority, when you
think that the processing of your data violates the provisions of the Regulation.

How long will your data be processed and stored?

Your personal data will be processed and stored for the duration of the financial contract and after that time can be
processed and stored for a period of prescription of possible claims.

Will the data be processed in an automated manner?

The above data will be processed in an automated manner, including profiling, where
the above data will be processed, inter alia, to assess the information the Data Administrator
has or will have.

I have read the information clause

………….…………………………………..
(Student’s signature)
 _________________________
place and date
____________________
Student’s Name and Surname

____________________
Adress

PERSONAL DATA PROCESSING AGREEMENT

I hereby agree/disagree* to the processing of my personal data by the University

of Economics and Human Sciences in Warsaw in the field of:
name, surname, date of birth, Passport number, PESEL/ID number, permanent adress, current adres,
phone number, e-mail adress, citizenship, sex, average grade.
My personal data can be used for recruitment purposes of Erasmus+ Program run
by University of Economics and Human Sciences in Warsaw for an indefinite period, no later than: untill
the cancellation of this consent.

….…………………………………..
Student’s signature