formularz.msz.pulawy.pl Open in urlscan Pro
185.7.107.148  Public Scan

URL: https://formularz.msz.pulawy.pl/
Submission: On July 20 via api from US — Scanned from PL

Form analysis 1 forms found in the DOM

<form>
  <div>
    <div class="nf-before-form-content"><nf-section>
        <div class="nf-form-fields-required">Pola oznaczone znakiem <span class="ninja-forms-req-symbol">*</span> są wymagane</div>
      </nf-section></div>
    <div class="nf-form-content "><nf-rows-wrap>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 100%;">
              <nf-fields><nf-field>
                  <div id="nf-field-133-container" class="nf-field-container hr-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-133-wrap" class="field-wrap hr-wrap" data-field-id="133">
                        <div class="nf-field-label"><label for="nf-field-133" id="nf-label-field-133" class="">Rozdzielacz Copy </label></div>
                        <div class="nf-field-element">
                          <hr class="ninja-forms-field">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-133" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 50%;">
              <nf-fields><nf-field>
                  <div id="nf-field-122-container" class="nf-field-container listselect-container  label-above  list-container">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-122-wrap" class="field-wrap listselect-wrap list-wrap list-select-wrap" data-field-id="122">
                        <div class="nf-field-label"><label for="nf-field-122" id="nf-label-field-122" class="">Kierunek I wyboru: <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <select id="nf-field-122" name="nf-field-122" aria-invalid="false" aria-describedby="nf-error-122" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-122" required="">
                            <option value="asystentka stomatologiczna W" selected="selected">asystentka stomatologiczna - kier. stacjonarny</option>
                            <option value="higienistka stomatologiczna W">higienistka stomatologiczna - kier. stacjonarny</option>
                            <option value="opiekun medyczny W">opiekun medyczny - kier. stacjonarny</option>
                            <option value="opiekun osoby starszej Z">opiekun osoby starszej - kier. zaoczny</option>
                            <option value="technik dentystyczny D">technik dentystyczny - kier. dzienny</option>
                            <option value="technik elektroniki i informatyki medycznej W">technik elektroniki i informatyki medycznej - kier. stacjonarny</option>
                            <option value="technik farmaceutyczny D">technik farmaceutyczny- kier. dzienny</option>
                            <option value="technik masazysta W">technik masażysta - kier. stacjonarny</option>
                            <option value="technik uslug kosmetycznych W">technik usług kosmetycznych - kier. stacjonarny</option>
                            <option value="technik uslug kosmetycznych Z">technik usług kosmetycznych - kier. zaoczny</option>
                            <option value="technik sterylizacji medycznej Z">technik sterylizacji medycznej- kier. zaoczny</option>
                            <option value="terapeuta zajeciowy W">terapeuta zajęciowy- kier. stacjonarny</option>
                            <option value="podolog W">podolog-kier. stacjonarny</option>
                          </select>
                          <div for="nf-field-122"></div>
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-122" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
            <div class="nf-cell" style="width: 50%;">
              <nf-fields><nf-field>
                  <div id="nf-field-116-container" class="nf-field-container listselect-container  label-above  list-container">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-116-wrap" class="field-wrap listselect-wrap list-wrap list-select-wrap" data-field-id="116">
                        <div class="nf-field-label"><label for="nf-field-116" id="nf-label-field-116" class="">Kierunek II wyboru: </label></div>
                        <div class="nf-field-element">
                          <select id="nf-field-116" name="nf-field-116" aria-invalid="false" aria-describedby="nf-error-116" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-116">
                            <option value="-" selected="selected">-WYBIERZ-</option>
                            <option value="asystentka stomatologiczna W">asystentka stomatologiczna - kier. stacjonarny</option>
                            <option value="higienistka stomatologiczna W">higienistka stomatologiczna - kier. stacjonarny</option>
                            <option value="opiekun medyczny Z">opiekun medyczny - kier. stacjonarny</option>
                            <option value="opiekun osoby starszej Z">opiekun osoby starszej - kier. zaoczny</option>
                            <option value="technik dentystyczny D">technik dentystyczny - kier. dzienny</option>
                            <option value="technik elektroniki i informatyki medycznej W">technik elektroniki i informatyki medycznej - kier. stacjonarny</option>
                            <option value="technik farmaceutyczny W">technik farmaceutyczny - kier. dzienny</option>
                            <option value="technik masazysta W">technik masażysta - kier. stacjonarny</option>
                            <option value="technik usug kosmetycznych W">technik usług kosmetycznych - kier. stacjonarny</option>
                            <option value="technik uslug kosmetycznych Z">technik usług kosmetycznych - kier. zaoczny</option>
                            <option value="technik sterylizacji medycznej Z">technik sterylizacji medycznej - kier. zaoczny</option>
                            <option value="terapeuta zajeciowy W">terapeuta zajęciowy - kier. stacjonarny</option>
                            <option value="podolog W">podolog - kier. stacjonarny</option>
                          </select>
                          <div for="nf-field-116"></div>
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-116" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 100%;">
              <nf-fields><nf-field>
                  <div id="nf-field-115-container" class="nf-field-container hr-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-115-wrap" class="field-wrap hr-wrap" data-field-id="115">
                        <div class="nf-field-label"><label for="nf-field-115" id="nf-label-field-115" class="">Rozdzielacz </label></div>
                        <div class="nf-field-element">
                          <hr class="ninja-forms-field">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-115" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 50%;">
              <nf-fields><nf-field>
                  <div id="nf-field-126-container" class="nf-field-container lastname-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-126-wrap" class="field-wrap lastname-wrap" data-field-id="126">
                        <div class="nf-field-label"><label for="nf-field-126" id="nf-label-field-126" class="">Imię <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-126" name="lname" autocomplete="family-name" aria-invalid="false" aria-describedby="nf-error-126" aria-labelledby="nf-label-field-126"
                            required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-126" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
            <div class="nf-cell" style="width: 50%;">
              <nf-fields><nf-field>
                  <div id="nf-field-121-container" class="nf-field-container lastname-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-121-wrap" class="field-wrap lastname-wrap" data-field-id="121">
                        <div class="nf-field-label"><label for="nf-field-121" id="nf-label-field-121" class="">Nazwisko <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-121" name="lname" autocomplete="family-name" aria-invalid="false" aria-describedby="nf-error-121" aria-labelledby="nf-label-field-121"
                            required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-121" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 35%;">
              <nf-fields><nf-field>
                  <div id="nf-field-119-container" class="nf-field-container phone-container  label-above  textbox-container">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-119-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="119">
                        <div class="nf-field-label"><label for="nf-field-119" id="nf-label-field-119" class="">PESEL <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-119" name="nf-field-119-phone" autocomplete="tel" aria-invalid="false" aria-describedby="nf-error-119" aria-labelledby="nf-label-field-119"
                            required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-119" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
            <div class="nf-cell" style="width: 65%;">&nbsp;</div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 43%;">
              <nf-fields><nf-field>
                  <div id="nf-field-138-container" class="nf-field-container date-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-138-wrap" class="field-wrap date-wrap" data-field-id="138">
                        <div class="nf-field-label"><label for="nf-field-138" id="nf-label-field-138" class="">Data urodzenia <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <div class="pikaday__container"><input id="nf-field-138" name="nf-field-138" aria-invalid="false" aria-describedby="nf-error-138" class="ninja-forms-field nf-element datepicker" aria-labelledby="nf-label-field-138"
                              required="" type="hidden" value="" placeholder="dd-mm-rrrr"><input type="text" class="pikaday__display pikaday__display--pikaday ninja-forms-field nf-element datepicker" placeholder="dd-mm-rrrr"></div>
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-138" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
            <div class="nf-cell" style="width: 57%;">
              <nf-fields><nf-field>
                  <div id="nf-field-136-container" class="nf-field-container city-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-136-wrap" class="field-wrap city-wrap" data-field-id="136">
                        <div class="nf-field-label"><label for="nf-field-136" id="nf-label-field-136" class="">Miejsce urodzenia <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-136" name="city" autocomplete="address-level2" aria-invalid="false" aria-describedby="nf-error-136" aria-labelledby="nf-label-field-136"
                            required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-136" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 100%;">
              <nf-fields><nf-field>
                  <div id="nf-field-120-container" class="nf-field-container html-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-120-wrap" class="field-wrap html-wrap" data-field-id="120">
                        <div class="nf-field-label"><label for="nf-field-120" id="nf-label-field-120" class="">ADRES ZAMIESZKANIA </label></div>
                        <div class="nf-field-element">
                          <p><b>ADRES ZAMIESZKANIA</b></p>
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-120" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 42%;">
              <nf-fields><nf-field>
                  <div id="nf-field-125-container" class="nf-field-container zip-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-125-wrap" class="field-wrap zip-wrap" data-field-id="125">
                        <div class="nf-field-label"><label for="nf-field-125" id="nf-label-field-125" class="">Kod pocztowy <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-125" name="zip" autocomplete="postal-code" aria-invalid="false" aria-describedby="nf-error-125" aria-labelledby="nf-label-field-125" required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-125" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
            <div class="nf-cell" style="width: 58%;">
              <nf-fields><nf-field>
                  <div id="nf-field-124-container" class="nf-field-container city-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-124-wrap" class="field-wrap city-wrap" data-field-id="124">
                        <div class="nf-field-label"><label for="nf-field-124" id="nf-label-field-124" class="">Miejscowość <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-124" name="city" autocomplete="address-level2" aria-invalid="false" aria-describedby="nf-error-124" aria-labelledby="nf-label-field-124"
                            required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-124" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 100%;">
              <nf-fields><nf-field>
                  <div id="nf-field-118-container" class="nf-field-container city-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-118-wrap" class="field-wrap city-wrap" data-field-id="118">
                        <div class="nf-field-label"><label for="nf-field-118" id="nf-label-field-118" class="">Ulica, nr domu <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-118" name="city" autocomplete="address-level2" aria-invalid="false" aria-describedby="nf-error-118" aria-labelledby="nf-label-field-118"
                            required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-118" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 100%;">
              <nf-fields><nf-field>
                  <div id="nf-field-117-container" class="nf-field-container city-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-117-wrap" class="field-wrap city-wrap" data-field-id="117">
                        <div class="nf-field-label"><label for="nf-field-117" id="nf-label-field-117" class="">Gmina/powiat/województwo <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-117" name="city" autocomplete="address-level2" aria-invalid="false" aria-describedby="nf-error-117" aria-labelledby="nf-label-field-117"
                            required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-117" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 100%;">
              <nf-fields><nf-field>
                  <div id="nf-field-129-container" class="nf-field-container textbox-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-129-wrap" class="field-wrap textbox-wrap" data-field-id="129">
                        <div class="nf-field-label"><label for="nf-field-129" id="nf-label-field-129" class="">NAZWA UKOŃCZONEJ SZKOŁY ŚREDNIEJ <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-129" name="nf-field-129" aria-invalid="false" aria-describedby="nf-error-129" aria-labelledby="nf-label-field-129" required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-129" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 58%;">
              <nf-fields><nf-field>
                  <div id="nf-field-139-container" class="nf-field-container city-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-139-wrap" class="field-wrap city-wrap" data-field-id="139">
                        <div class="nf-field-label"><label for="nf-field-139" id="nf-label-field-139" class="">Miejscowość <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-139" name="city" autocomplete="address-level2" aria-invalid="false" aria-describedby="nf-error-139" aria-labelledby="nf-label-field-139"
                            required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-139" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
            <div class="nf-cell" style="width: 42%;">
              <nf-fields><nf-field>
                  <div id="nf-field-130-container" class="nf-field-container date-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-130-wrap" class="field-wrap date-wrap" data-field-id="130">
                        <div class="nf-field-label"><label for="nf-field-130" id="nf-label-field-130" class="">DATA /data ze świadectwa/ <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <div class="pikaday__container"><input id="nf-field-130" name="nf-field-130" aria-invalid="false" aria-describedby="nf-error-130" class="ninja-forms-field nf-element datepicker" aria-labelledby="nf-label-field-130"
                              required="" type="hidden" value="" placeholder="DD-MM-RRRR"><input type="text" class="pikaday__display pikaday__display--pikaday ninja-forms-field nf-element datepicker" placeholder="DD-MM-RRRR"></div>
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-130" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 38%;">
              <nf-fields><nf-field>
                  <div id="nf-field-131-container" class="nf-field-container phone-container  label-above  textbox-container">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-131-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="131">
                        <div class="nf-field-label"><label for="nf-field-131" id="nf-label-field-131" class="">Numer telefonu <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-131" name="phone" autocomplete="tel" aria-invalid="false" aria-describedby="nf-error-131" aria-labelledby="nf-label-field-131" required="">
                        </div>
                      </div>
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                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-131" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
            <div class="nf-cell" style="width: 62%;">
              <nf-fields><nf-field>
                  <div id="nf-field-134-container" class="nf-field-container email-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-134-wrap" class="field-wrap email-wrap" data-field-id="134">
                        <div class="nf-field-label"><label for="nf-field-134" id="nf-label-field-134" class="">E-mail <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-134" name="email" autocomplete="email" aria-invalid="false" aria-describedby="nf-error-134" aria-labelledby="nf-label-field-134" required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-134" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
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          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 100%;">
              <nf-fields><nf-field>
                  <div id="nf-field-135-container" class="nf-field-container hr-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-135-wrap" class="field-wrap hr-wrap" data-field-id="135">
                        <div class="nf-field-label"><label for="nf-field-135" id="nf-label-field-135" class="">Rozdzielacz </label></div>
                        <div class="nf-field-element">
                          <hr class="ninja-forms-field">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-135" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 100%;">
              <nf-fields><nf-field>
                  <div id="nf-field-167-container" class="nf-field-container textarea-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-167-wrap" class="field-wrap textarea-wrap" data-field-id="167">
                        <div class="nf-field-label"><label for="nf-field-167" id="nf-label-field-167" class="">Skąd dowiedział się Pan/Pani o naszej szkole? </label></div>
                        <div class="nf-field-element">
                          <textarea id="nf-field-167" name="nf-field-167" aria-invalid="false" aria-describedby="nf-error-167" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-167"></textarea>
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-167" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
          </nf-cells>
        </div>
        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 50%;">
              <nf-fields><nf-field>
                  <div id="nf-field-132-container" class="nf-field-container checkbox-container  label-right ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-132-wrap" class="field-wrap checkbox-wrap" data-field-id="132">
                        <div class="nf-field-label"><label for="nf-field-132" id="nf-label-field-132" class="">-Zobowiązuję się do dostarczenia dokumentów w oryginale osobiście lub pocztą: świadectwo ukończenia szkoły średniej, 2 zdjęcia
                            legitymacyjne, do 28 sierpnia 2023r. r. <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input id="nf-field-132" name="nf-field-132" aria-describedby="nf-error-132" class="ninja-forms-field nf-element" type="checkbox" value="1" aria-labelledby="nf-label-field-132" required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-132" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
            <div class="nf-cell" style="width: 50%;">
              <nf-fields><nf-field>
                  <div id="nf-field-123-container" class="nf-field-container checkbox-container  label-right ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-123-wrap" class="field-wrap checkbox-wrap" data-field-id="123">
                        <div class="nf-field-label"><label for="nf-field-123" id="nf-label-field-123" class="">-Wyrażam zgodę na przetwarzanie danych osobowych w zakresie niezbędnym do przeprowadzenia rekrutacji w Szkole Policealnej – Medyczne
                            Studium Zawodowym im. PCK w Puławach, <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input id="nf-field-123" name="nf-field-123" aria-describedby="nf-error-123" class="ninja-forms-field nf-element" type="checkbox" value="1" aria-labelledby="nf-label-field-123" required="">
                        </div>
                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-123" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
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                </nf-field></nf-fields>
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        <div class="nf-row">
          <nf-cells>
            <div class="nf-cell" style="width: 50%;">
              <nf-fields><nf-field>
                  <div id="nf-field-128-container" class="nf-field-container spam-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-128-wrap" class="field-wrap spam-wrap" data-field-id="128">
                        <div class="nf-field-label"><label for="nf-field-128" id="nf-label-field-128" class="">ile jest 3 razy 6 - wpisz wynik <span class="ninja-forms-req-symbol">*</span> </label></div>
                        <div class="nf-field-element">
                          <input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-128" name="nf-field-128" aria-invalid="false" aria-describedby="nf-error-128" aria-labelledby="nf-label-field-128" required="">
                        </div>
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                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-128" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field><nf-field>
                  <div id="nf-field-127-container" class="nf-field-container submit-container  label-above  textbox-container">
                    <div class="nf-before-field"><nf-section>
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                    <div class="nf-field">
                      <div id="nf-field-127-wrap" class="field-wrap submit-wrap textbox-wrap" data-field-id="127">
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                        <div class="nf-field-element">
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                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-127" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
            </div>
            <div class="nf-cell" style="width: 50%;">
              <nf-fields><nf-field>
                  <div id="nf-field-137-container" class="nf-field-container date-container  label-above ">
                    <div class="nf-before-field"><nf-section>
                      </nf-section></div>
                    <div class="nf-field">
                      <div id="nf-field-137-wrap" class="field-wrap date-wrap" data-field-id="137">
                        <div class="nf-field-label"><label for="nf-field-137" id="nf-label-field-137" class="">Data </label></div>
                        <div class="nf-field-element">
                          <div class="pikaday__container"><input id="nf-field-137" name="nf-field-137" aria-invalid="false" aria-describedby="nf-error-137" class="ninja-forms-field nf-element datepicker" aria-labelledby="nf-label-field-137"
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                      </div>
                    </div>
                    <div class="nf-after-field"><nf-section>
                        <div class="nf-input-limit"></div>
                        <div id="nf-error-137" class="nf-error-wrap nf-error" role="alert"></div>
                      </nf-section></div>
                  </div>
                </nf-field></nf-fields>
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          </nf-cells>
        </div>
      </nf-rows-wrap></div>
    <div class="nf-after-form-content"><nf-section>
        <div id="nf-form-errors-7" class="nf-form-errors" role="alert"><nf-errors></nf-errors></div>
        <div class="nf-form-hp"><nf-section>
            <label for="nf-field-hp-7" aria-hidden="true">
              <input id="nf-field-hp-7" name="nf-field-hp" class="nf-element nf-field-hp" type="text" value="">
            </label>
          </nf-section></div>
      </nf-section></div>
  </div>
</form>

Text Content

 


REKRUTACJA –  2024/2025

Uwaga: ta zawartość wymaga obsługi języka JavaScript.
Pola oznaczone znakiem * są wymagane
Rozdzielacz Copy

--------------------------------------------------------------------------------


Kierunek I wyboru: *
asystentka stomatologiczna - kier. stacjonarny higienistka stomatologiczna -
kier. stacjonarny opiekun medyczny - kier. stacjonarny opiekun osoby starszej -
kier. zaoczny technik dentystyczny - kier. dzienny technik elektroniki i
informatyki medycznej - kier. stacjonarny technik farmaceutyczny- kier. dzienny
technik masażysta - kier. stacjonarny technik usług kosmetycznych - kier.
stacjonarny technik usług kosmetycznych - kier. zaoczny technik sterylizacji
medycznej- kier. zaoczny terapeuta zajęciowy- kier. stacjonarny podolog-kier.
stacjonarny


Kierunek II wyboru:
-WYBIERZ- asystentka stomatologiczna - kier. stacjonarny higienistka
stomatologiczna - kier. stacjonarny opiekun medyczny - kier. stacjonarny opiekun
osoby starszej - kier. zaoczny technik dentystyczny - kier. dzienny technik
elektroniki i informatyki medycznej - kier. stacjonarny technik farmaceutyczny -
kier. dzienny technik masażysta - kier. stacjonarny technik usług kosmetycznych
- kier. stacjonarny technik usług kosmetycznych - kier. zaoczny technik
sterylizacji medycznej - kier. zaoczny terapeuta zajęciowy - kier. stacjonarny
podolog - kier. stacjonarny


Rozdzielacz

--------------------------------------------------------------------------------


Imię *


Nazwisko *


PESEL *


 
Data urodzenia *


Miejsce urodzenia *


ADRES ZAMIESZKANIA

ADRES ZAMIESZKANIA


Kod pocztowy *


Miejscowość *


Ulica, nr domu *


Gmina/powiat/województwo *


NAZWA UKOŃCZONEJ SZKOŁY ŚREDNIEJ *


Miejscowość *


DATA /data ze świadectwa/ *


Numer telefonu *


E-mail *


Rozdzielacz

--------------------------------------------------------------------------------


Skąd dowiedział się Pan/Pani o naszej szkole?


-Zobowiązuję się do dostarczenia dokumentów w oryginale osobiście lub pocztą:
świadectwo ukończenia szkoły średniej, 2 zdjęcia legitymacyjne, do 28 sierpnia
2023r. r. *


-Wyrażam zgodę na przetwarzanie danych osobowych w zakresie niezbędnym do
przeprowadzenia rekrutacji w Szkole Policealnej – Medyczne Studium Zawodowym im.
PCK w Puławach, *


ile jest 3 razy 6 - wpisz wynik *



Data