To fill in and return to the relevant Department of Medicine

FORM FOR THE REMBURSEMENT OF EXPENSES INCURRED DURING FREE
OCCASIONAL OR SPORADIC EMPLOYMENT (RISOLUZIONE 49/E/2013)-NOT RESIDENT

I, First Name           _______________________________  Surname _______________________________
Middle Name	_______________________________   Sex     M  F 
Place of birth - Country______________________________  Town_______________________________
Date of birth 	_______________________________  Citizenship _____________________________
Telephone no. - Home_________________  Office ____________________Mobile___________________  
Email___________________________________
Passport no.	   _______________________________   Valid until ______________________________

Residency (for tax purposes)  Address  _______________________________________________________
		       Town      _________________________________ ZIP/Post Code __________
		       Country   _______________________________________________________
Foreign taxpayer reference/identification number _____________________________
Italian taxpayer identification no.- Codice Fiscale (If you have one) 
I DECLARE that for the professional service provided here I will not ask for any fee but only for the reimbursement of expenses I have incurred
I ASK to have the reimbursement paid into:
Bank: _________________________________________________________________________________
Account no. (with myself as beneficiary)______________________________________________________
IBAN ________________________________________________________
Routing _______________________________________________________________________________
Bic/Swift ______________________________________________________________________________

Declaration

The information I have given in this form is correct and complete to the best of my knowledge and belief.
I must inform University of Padova immediately of any changes to the information that I provided.

Date: ______________						Signature:___________________________

Privacy and Data Protection

I consent to the use of the above information in accordance to Titolo III, capo I and II of D. Lgs. 30 June 2003 no. 196 (Privacy and Data Protection) for the purpose of fulfilling the obligations arising from the contract between myself and University of Padova.

Date: ______________						Signature:___________________________