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Please fill in this form and submit it to us.



PERSONAL INFORMATION | أسئلة
My live is in danger | حياتي في خطر
Yes | نعم
No | لا
I want to start a new life in Poland | أريد أن أبدأ حياة جديدة في بولندا
Yes | نعم
No | لا
I don't care about the conditions of help. I just want to be safe and have possibility to get any kind of work |
لا يهمني ما هي شروط المساعدة فقط أريد أن أكون بأمان ويكون لدي فرصة متاحة للعمل
Yes | نعم
No | لا
Name | الأسم
Surname | الكنية
Date of birth | تاريخ الميلاد
Age | العمر
Your gender | الجنس
Male | ذكر
Female | أنثى
Where do you live | مكان السكن
Your e-mail address | عنوان الايميل
Your phone number | رقم هاتفك
Your Facebook profile | اسم الفيس بوكFACEBOOK
Your passport number | رقم جواز السفر
Your ID number | الهوية
Your education | الدرجة التعليمية
What is your profession? | العمل
What is your former profession? | العمل السابق
Do you have any health problems? | مشاكل صحية
What is your church? | الكنيسة
What is your church address? | عنوان الكنيسة
What is your Priest of Pastor name? | اسم الأب الروحي في الكنيسة
What is your Priest of Pastor phone number? | رقم الأب الروحي للكنيسة
What is your Priest of Pastor email address? | البريد الالكتروني للأب الروحي
Baptism certificat | شهادة معمودية
What is your baptism date? | تاريخ العماد المقدس
MONEY AND COSTS
What kind of help you are applying for? | ما هو نوع المساعدة الذي ترغب به؟
Visa to Poland - I want to start new life
تأشيرة دخول الى بولندا-- أريد بدء حياة جديدة في بولاندا
Visa to Europe- I just want to get to Europe
تأشيرة دخول الى أوروبا --أريد الحصول على اللجوء في بلد اخر
Passport / travel pass:
I have a travel pass or passport
I don't have a travel pass or passport
Plane ticket:
I have money to buy a tickets for me and my family
I don't have enough money
Costs of hotel in Lebanon (time for applying for visa in Beirut is 14 days after receiving the application):
I will pay the costs by myself
I don't have any money to pay for the stay, I have nobody I can stay with
Transport to Lebanon:
I can afford to travel on my own
I don't have any money to go to Lebanon
LIVING IN POLAND
Where do you prefer to live in Poland (we don't know if we will be able to help you with the choice but we will take you preferences under consideration):
Big city
Town
Village
Can you live in Poland with a family that will sponsor you?
Yes, I can live in their house
No, I would prefer to live separately
Can you live with another Syrian Christian family in the same house or big apartment?
Yes, I can live with other Syrian family
No, I would prefer to live separately
Do you have any relatives in Poland and you want to live with them?
I want to live with my relatives which already are in Poland
No, I have no relatives in Poland
YOUR FAMILY MEMBERS TRAVELING WITH YOU
How many persons of your family will accompanying you?
FAMILY MEMBER NO. 1
Family member's gender
Male
Female
Will this person live together with you in Poland?
Yes, this person will live together
No, this person wants to live separately


FAMILY MEMBER NO. 2
Family member's gender
Male
Female
Will this person live together with you in Poland?
Yes, this person will live together
No, this person wants to live separately


FAMILY MEMBER NO. 3
Family member's gender
Male
Female
Will this person live together with you in Poland?
Yes, this person will live together
No, this person wants to live separately


FAMILY MEMBER NO. 4
Family member's gender
Male
Female
Will this person live together with you in Poland?
Yes, this person will live together
No, this person wants to live separately


FAMILY MEMBER NO. 5
Family member's gender
Male
Female
Will this person live together with you in Poland?
Yes, this person will live together
No, this person wants to live separately


FAMILY MEMBER NO. 6
Family member's gender
Male
Female
Will this person live together with you in Poland?
Yes, this person will live together
No, this person wants to live separately


JOB
I will take any job available
Yes
No, I prefer to work in my profession
I will take job in service:
Cleaning
Cooking
Gardening
Housekeeping
Childcare
Driving
Cosmetics/hairstyle
Working in factory
Other
I don't want to work, I want to study
Yes, I want to go to school
No, I'm ready to work
MY STORY OF LIFE
Did you experience any persecution?
Yes
No
Did you or your relatives hurt because of the war?
Yes
No
BEING AN AMBASSADOR
Are you willing to be an Ambassador of Chrystian Syrians in Poland?
Yes
No
Our goal is to help as much Christians as possible. Are you willing to help us to help other Chrystian Syrians?
Yes
No
Are you willing to say positive things about the help to the media (press, tv, radio starions)?
Yes
No
Are you willing to stay in contact and thank your supporters that will help you and sponsor you?
Yes
No
Can we give your pictures to the supporters to find a supporter that will sponsor you're stay in Poland?
Yes
No
Will you have a positive attitude toward help given to you?
Yes
No
Are you willing to become self-reliant and independent as soon as possible?
Yes
No
Will you learn Polish language and try to assimilate with Polish society?
Yes
No




IDEA BANK POLAND

PLN: 31 1950 0001 2006 0846 8518 0002
EUR: 04 1950 0001 2006 0846 8518 0003
USD: 74 1950 0001 2006 0846 8518 0003
GBP: 47 1950 0001 2006 0846 8518 0005

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