Application for Admission Czech for Foreigners

I want to apply for a course Czech for foreigners:

One year Intensive Language Course for 4 - 8 students intending to study

at Palacky University (590 lessons)

Personal information

1. Family name:

2. First name:

3. Nationality:

4. Gender:  Male  Female

5. Date of birth: Day: Month: Year: Place of birth:

6. Passport number: Valid until:

7. Visa Application at the Ambassy in: City: Country:

8. After an Intensive Course Czech for foreigners I´d like to study (major/subject):

9. Permanent address: Street / City / State / ZIP Code:

Phone E-mail:

10. Address for communication/correspondence: Street / City / Country / ZIP Code:

Phone: E-mail:

11. Person to be notified in a case of emergency:

Name: Relationship:

Address:

Phone: E-mail:

Accommodation at UP Dormitory

Arrival: Departure:

Smoker:  yes  no

Name(s) of any student(s) with whom you would like to share a room:

If no, would you mind sharing accommodation with smokers?

 yes  no

Language knowledge

1. Have you ever studied Czech?  yes  no

Which organization, school or institute and the length of studies?

2. Level of Czech language:  A0  A1  A2  B1  B2  C1

3. Other languages – level:

Education:

1. What secondary school did you study?

2. Successful graduation from this school is a condition for entering university/college in my country.  yes  no

Date: Student´s signature:

How to apply for Admission – checklist

Complete all parts of the Application form and send it back by e-mail together with copies of other required documents (a passport, Secondary School and University Diplomas) to the:

Philosophical Faculty of Palacky University Olomouc

Centre for Distance Learning

Mgr. Veronika Glogarová

tr. Svobody 26

771 80 Olomouc

Czech Republic

E-mail:

Phone: +420 585 633 476

The refund of 75% of the whole school-fee will be sent back to the applicant who doesn´t get a visa or who cancels the attendance in the Czech course.