PROM Application Form / Department of International Cooperation

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ATTENTION!

The assessment committee will only consider information provided in this PROM application form. All fields marked with * are mandatory. If a field does not apply to your trip, please enter “NOT APPLICABLE”. If you make a mistake or need to resubmit your application, please contact Dr. Paweł Truszkiewicz: P.Truszkiewicz@dwz.uz.zgora.pl.

Purpose of the trip (activity): *

Please select an option.

Applicant status: *

Please select an option.

INFORMATION I

Candidate’s data and address

First name: *

Please complete the field.

Last name: *

Please complete the field.

Academic title/degree:

Please complete the field.

Date of birth: *

Please select a date.

Street and house number: *

Please complete the field.

Postal code: *

Please complete the field.

City: *

Please complete the field.

Country: *

Please complete the field.

Contact phone number: *

Please complete the field.

Email address: *

Please complete the field.

* required field

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Trip information

Sending university: *

Please complete the field.

Address of the sending university – City: *

Please complete the field.

Address of the sending university – Country: *

Please complete the field.

Planned start date of mobility (departure date): *

Please select a date.

Planned end date of mobility (return date): *

Please select a date.

Number of days at University of Zielona Góra: *

Please complete the field.

Host unit at UZ *

Please complete the field.

Your contact person at UZ *

Please complete the field.

* required field

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Are there costs related to renting equipment or purchasing services necessary to ensure participation of persons with special needs?

Additional costs *

Please select an option.

If YES, briefly describe the cost and purpose:

Additional costs

Please complete the field.

* required field

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INFORMATION III

Bank account details for mobility support transfer

Bank name *

Please complete the field.

Bank SWIFT code *

Please complete the field.

Transfer is made in PLN

Bank account number *

Bank account number in IBAN format, e.g. PL05 1090 2402 1842 2778 9664 8467

Please enter your bank account number in IBAN format.

Currency of the account

Please complete the field.

* required field

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INFORMATION IV

Below, you must attach the completed “Annex to the PROM application form” in editable (Word) format. This application will be the basis for the assessment and evaluation. The application is available on the project website https://welcomecenter.uz.zgora.pl/projects/prom in the “Available documents” menu.

Annex to the PROM application form *

Annex to the PROM application form

select file

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Please attach the appropriate file.

I declare that the information provided in the PROM application form is true. I declare that I have read the PROM Program Implementation Rules published at http://www.welcomecenter.uz.zgora.pl and meet the recruitment criteria for PROM trips. I consent to the processing of my personal data for the purposes of the PROM Program in accordance with Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation), and the Act of 29 August 1997 on the protection of personal data (Journal of Laws 1997 No. 133, item 883, as amended). I declare that I have obtained my supervisor’s consent to apply for participation in the Program.

Declaration *

Please select an option.

I declare that I have read the “Information clause of the University of Zielona Góra regarding the processing of personal data of participants in projects funded by European Social Fund for Social Development 2021-2027 (FERS)” available on the Project website.

Declaration II *

Please select an option.

* required field