Application form

Your name

Your previous name

(If you have changed your name before)

Your last name

Your previous surname

(If you have previously changed your last name)

What is your father's name?

Your mother's name

Mother's Maiden Name

Your date of birth

Your Gender

City where you were born

Country

Nationality

Citizenship

Marital status

Education

Height

Eye color

Special features

Tattoos, scars, birthmarks

PESEL number

If there is no PESEL number, enter eleven nines (99999999999)

Your polish phone number

Your e-mail

Are your family members in Poland?

Yes

No

Residence address in Poland

The purpose of obtaining a residence card

Family members residing in the territory of the Republic of Poland

It is necessary to indicate: First and last name, gender, date of birth, degree of kinship, citizenship, residential address, whether the person has applied for a card, whether he/she is in your care

List all your previous trips to Poland over the last 5 years.

Are you currently in Poland?

Yes

No

Date of your last entry

On what basis are you on the territory of the Republic of Poland?

List your foreign trips (excluding trips to Poland over the last 5 years)

Monthly Income Information

What is the official salary?

Information about health insurance

If you are officially employed, indicate ZUS p ZUA. If you use the services of a private insurance company, indicate the company name and insurance policy number.