CENTRE OF EXCELLENCE

			Institute of Mathematics
	    Stefan Banach International Mathematical Centre
		       as a Centre of Excellence

			    APPLICATION FORM
			    ----------------

Current family name:

First name:

Birth family name: 

Date of birth (dd/mm/yyyy):
Gender (F/M):

Nationality:

Place of permanent residence:


From when:
Address:



E-mail:                                   Fax:

The package the candidate would like to join:

Expected length and period of visit in the Centre: