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(first and second name, sumame)

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(city)

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zip code, post office.......................

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phone..........................................

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(e-mail)

.........................dn............20............r

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The Priory of the Brotherhood

of the Order of St. Stanislas

in .......................................................................

l hereby request to oount me among the Dames and Knights of the Order of St. Stanislas

l hereby also inform that l am aware of the fact that in case of appointing me into the Order of St. Stanislas, in the period between the decision of the respectlve Chapter about the appointment and the day of an lnvestiture i shall obtain the status of a postulani with alt its rights and duties.

Also, according to art 23, par 1 point 1 and par. 1 point 2 of the Law on personal data protection as of 29th August 1997 (Journal of Law as of 2002, No 101, item 936 as amended) l hereby agree for the Brotherhood of the Order of St, Stanislas to process the foilowing data that l willingly give for the statutory purposes of the Order,

PESEL..............................................................

Mothei’s name:..................................................

Father’s name..............................................

Nazwisko rodowe matki..................................

Fathei’s family crest ........................................       Mother's family crest.....................................

Date of brith....................................................      Place of brith.............................................

Contry............................................................       Province....................................................

Nationalites.................................

Confession.......................................................      Marital status..............................................

Holy Ordesrs........................................................................

Spouse’s name..................................................    Children’s names...........................................

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Educatlon, profession academic gualifications................................................................................

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