(class of Order or the name of the award)

(surname)

(first name)

(datę of birth)

(date of joining the Order)

(function in the Order)

(home address)

Cross of the Order of St Stanislas (             StS)

(recentły awarded medal of the Order St. Stanislas)

(date (yers) of awarding)

Explanation of the application

..........................................

(date and signature of the proposer)

(signature of the Grand Prior of Poland)

(opinion ofthe Grand Prioty of Poland)

THE DECISION OF THE GRAND MASTER

..............................

(signature of the Grand Master)

No, of the diploma

(date)