Personal data questionnaire data concerning residence in poland

PERSONAL DATA QUESTIONNAIRE - DATA CONCERNING RESIDENCE IN POLAND

1. 
   ADDRESS IN POLAND (mandatory fields*)
   

Name
Passport №
E-Mail
Phone №
City
Street, House/Apt №
Postal Code

2. 
   PROXY’S PERSONAL DATA
   

* If you are not domiciled or habitually resident in the Republic of Poland, please indicate a service agent to whom the correspondence will be delivered.

If you do not indicate the service agent, please be informed that your letters will be kept in your personal file deemed delivered in accordance with Article 40 para. 4 and 5 of the Code of Administrative Procedure of 14 June 1960 (Journal of Laws 1960, No. 30, item. 168 as amended)

Name
City
Street, House/Apt №
Postal Code

………..…/………….../20…….… …………………………………

Date: Signature: