APPLICATION FORM
MASTER OF BUSINESS ADMINISTRATION
POSTGRADUATE PROGRAMS IN ENGLISH
TAUGHT WITH SUPPORT FROM
WOODBURY SCHOOL OF BUSINESS, UTAH VALLEY UNIVERSITY
Choose the program you apply for:
EXECUTIVE MBA
MBA – INNOVATION AND DATA ANALYSIS
Please type (in exceptional cases write clearly and legibly using capital letters)
1. YOUR PERSONAL DETAILS
Surname/Family name:
Title: Mr./Mrs./Miss/Dr.
(please circle)
First/Given Name and Other Name/s:
Parents’ names
Father’s:
Date of birth (dd/mm/yy)
Mother’s:
/
/
Permanent Address
Female
Male
Correspondence Address (if different)
Street:
City:
Zip/Post-code:
Country:
From (date)
Telephone (landline):
Fax:
Telephone (mobile):
Email:
Institute of Computer Science Polish Academy of Sciences
5 Jana Kazimierza St., 01-248 Warsaw, Poland
Until (date)
tel. +48 22 380 0586, fax +48 22 380-05-10
e-mail: study@ipipan.waw.pl, www.ipi.edu.pl/en
Your country of citizenship:
Place of Birth:
Your passport:
Country:
Series:
Number:
Permanent residency in Poland?
Valid until:
Yes:
No:
2. EDUCATION/DEGREES OBTAINED (all fields have to be filled in)
Secondary / High School:
Name of School:
Address:
Country:
Years of studies:
BA degree or a BA degree equivalent:
Name of School:
Address:
Institute of Computer Science Polish Academy of Sciences
5 Jana Kazimierza St., 01-248 Warsaw, Poland
tel. +48 22 380 0586, fax +48 22 380-05-10
e-mail: study@ipipan.waw.pl, www.ipi.edu.pl/en
Country:
Years of studies:
Field of studies:
Degree Obtained (if none, then indicate the number of years completed):
MA degree or an MA degree equivalent:
Name of School:
Address:
Country:
Years of studies:
Field of studies:
Degree Obtained (if none, then indicate the number of years completed):
Institute of Computer Science Polish Academy of Sciences
5 Jana Kazimierza St., 01-248 Warsaw, Poland
tel. +48 22 380 0586, fax +48 22 380-05-10
e-mail: study@ipipan.waw.pl, www.ipi.edu.pl/en
3. CURRENT OCCUPATION
Company/Organization
Name and Address:
Your position:
4. APPLICATION PACKAGE (Please make sure that you collect all the documents below and
send them together with the completed application form to study@ipipan.waw.pl as
attachments):
 Curriculum Vitae (Resume) written in English;
 copy of your BA/BSc (or MA/MSc) diploma together with its transcript (if the diploma
is issued in any other language than Polish, English or Russian, certified translation
should be provided to any of the above languages);
 copy of your passport or official ID (only the page(s) showing your name, picture and
passport number).
5. DECLARATION
The statements on this form are to the best of my knowledge and belief correct. I understand
that my acceptance will be based upon the information given in this form, and that if I am found
to have given false information, the acceptance may be withdrawn. I understand that the
information supplied on this form will be retained by the Institute of Computer Science of the
Polish Academy of Sciences and will be used for the purpose of processing my application. In
the event that my application is successful I understand that the information will form part of my
participant record. I agree to have my personal data processed during the admission process at
the Institute of Computer Science of the Polish Academy of Sciences in accordance with the Act
of 29 August 1997 on the Protection of Personal Data (unified text: Journal of Laws of 2014, item
1182 with amendments).
Signed………………............................................…………
Institute of Computer Science Polish Academy of Sciences
5 Jana Kazimierza St., 01-248 Warsaw, Poland
Date…………………………………
tel. +48 22 380 0586, fax +48 22 380-05-10
e-mail: study@ipipan.waw.pl, www.ipi.edu.pl/en