ࡱ> L4bjbj4@ 228\*$ "$NddddD!F!F!F!F!F!F!$1$&>j!]"j!22ddU!oood28ddD!oD!oo:(,jdܼ?T 0!!0 "^R'?0''loj!j!o "' : SHAPE \* MERGEFORMAT  Nr Ewidencyjny  Stowarzyszenie Absolwentw Politechniki BiaBostockiej DEKLARACJA Niniejszym prosz o przyjcie mnie do Stowarzyszenia Absolwentw Politechniki BiaBostockiej DANE OSOBISTE Imiona i nazwisko............................................................................................................................ Data i miejsce urodzenia................................................................................................................. Miejsce zatrudnienia........................................................................................................................ Telefon komrkowy:........................................................................................................................ Adres do korespondencji................................................................................................................ ......................................................................................................................................................... E-mail.............................................................................................................................................. WYKSZTAACENIE ZAWODOWE WydziaB/Kierunek............................................................................................................................. Rok ukoDczenia................................................... Uzyskany tytuB............................................... Zobowizuj si do aktywnego uczestnictwa w |yciu Stowarzyszenia Wyra|am rwnie| zgod naprzetwarzanie przez Politechnik BiaBostock moich danych osobowychwzakresie okre[lonym wniniejszej deklaracji absolwenta. Jednocze[nie o[wiadczam, |ejestem [wiadoma/y dobrowolno[ci podania danych oraz, |e zostaBam/em poinformowana/y oprawie wgldu dotre[ci moich danych oraz mo|liwo[ci ichpoprawiania. PODPIS KANDYDATA Data..................................................................... Podpis........................................................ DECYZJA ZARZDU (wypeBnia Zarzd Stowarzyszenia) Przyjta/y do Stowarzyszenia Absolwentw Politechniki BiaBostockiej na czBonka: & & & & & & & & ................................... (wybra: zwyczajnego, wspierajcego) Uwagi.............................................................................................................................................. Data.............................................. 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WypeBnion i podpisan deklaracj nale|y wysBa listownie na poni|szy adres do Sekretarza Stowarzyszenia, albo po zeskanowaniu przesBa elektronicznie na adres e-mailowy: absolwenci@pb.edu.pl Stowarzyszenie Absolwentw Politechniki BiaBostockiej mgr Julia Siderska WydziaB Zarzdzania Politechniki BiaBostockiej ul. O. Tarasiuka 2 16-001 Kleosin, woj. podlaskie Wszelkie pytania mo|na kierowa do Sekretarza Stowarzyszenia na adres e-mailowy: absolwenci@pb.edu.pl. Na podstawie art.24 ust.1 ustawy zdnia 29sierpnia 1997roku oochronie danych osobowych (Dz.U.z2002r. Nr101, poz.926 zpzn.zm.): administratorem danych jest Politechnika BiaBostocka zsiedzib wBiaBymstoku, przy ul.Wiejskiej45A, 15-351BiaBystok. 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