Facsimile of application form 

To the Head of the Department of Medicine

at the University of Padova

The undersigned____________________________________________________________________
born in __________________________________________________________________[insert city, country]  on__________________, resident at _____[insert house number], ________________________________________________________________ [insert street name], ____________ [insert postcode,]  
of _________________________nationality, having telephone no.  _________________________, e-mail _______________________and certified e-mail (PEC): ______________________________

HEREBY REQUESTS
to be admitted to the following selection process, through the evaluation of qualifications or qualifications and interview process for the awarding of a research fellowship entitled:
___________________________________________________________________________
The selection process has been authorised by provision of Reg. no. ____  Record no. ……… dated ….

HEREBY DECLARES
in accordance with Articles 46 and 47 of Presidential Decree No. 445 of 28 December 2000, being aware of the administrative and criminal penalties referred to in Article 75 (Forfeiture of benefits) and Article 76 (Criminal provisions) in cases of forgery of documents and making false statements,
•	to possess the following qualifications:
 _____________________________________________________________________________
•	to be a citizen of  _____________________ [if not an European Union citizen and present on Italian territory: declares to have a valid residence permit on the deadline date of the application];
•	to have read the University's "Regulations Governing Research Fellowships" and to not be in any condition that provides for ineligibility, and not to have family or kinship relationships up to the fourth degree with lecturers or researchers working at the Department elected as "Research Base", or with Rector, or Director General, or a member of the University Board of Governors;
•	to be actually involved in the following working activities:
______________________________________________________________________________________________________________________________________________________
•	to give their address for the managing of the selection process:
o	Home Address
o	to the following address:
______ [house number], __________________________________________ [street], __________________________________________[city], __________________________________________[country] _______________________________________________ [postcode]

Pursuant to Art. 20 of Law no.104/1992, the applicant requires the following arrangements for interview process _________________________________________________________________________________and attaches relevant disability certification.  

Declares to be aware and consents that the data provided in this declaration can be treated in compliance with Legislative Decree no. 196/2003 and subsequent amendments and modifications, for all matters relating to managing of this selection process.

The application shall be accompanied by the following:
a) a CV detailing professional, academic and research background;  
b) copy of an identity document;
c) any other documentation as indicated in the selection announcement;
d) any other documentation deemed relevant for the evaluation. 

Date__________________________
Applicant's signature
________________________________________________

This document is also translated into English for informational purposes only; for all legal purposes, only the Italian version is valid.