TO THE HEAD OF THE DEPARTMENT OF SURGICAL SCIENCES, ONCOLOGY AND GASTROENTEROLOGY – DISCOG
The undersigned

Surname	Name	Italian tax payer's code 
(codice fiscale);	

		
Date of birth	Place of birth	Province or Country of birth (if foreign)	

		
Fixed address	Municipality	Province or Country of fixed residence (if foreign)	

		
Post code	Telephone no.	Email address	

Domicile address	Municipality	Province or Country of domicile address (if foreign)	

Post code	Telephone no.	Email address	

hereby requests

to be admitted to the public selection procedure by qualifications and interview for the awarding of a research grant entitled “.…………………………….” for the duration of …… years, at the Department/Centre of ……….……………. at the University of Padua.

For this purpose,

in accordance with Art. 46 and 47 of Presidential Decree DPR no. 445 dated 28 December 2000 and being aware of the administrative and criminal penalties laid down by Art. 75 (Loss of Benefits) and Art. 76 (Criminal Proceedings) in the event of forgery in deeds and false declarations, 

he/she hereby declares that

	he/she is a .................................. citizen;
	he/she has a university degree awarded in academic year ……… on ………. at ………;
	he/she has carried out documented post-graduate research activity in the academic field outlined in the selection announcement;
	he/she has a PhD awarded in academic year ……… on ………. at ………;
	he/she is not a permanent employee at the universities or other organisations listed in Art. 22 of Law 240/2010; 
	he/she is aware that Art. 18 of Law 240/2010 envisages the extension of incompatibility with a research grant award to: “anyone who is related or has an affinity, up to and including the fourth degree of kinship, to a professor working in the department or centre where the research is based, or to the Rector, Director General, or a member of the university's Administrative Board.”

He/She also declares

	that he/she has stated true information in the academic and professional curriculum vitae, attached and signed on each page, pertaining to the research activity within the selection announcement;
	that the copies of the following qualifications:
1.
2.
3.
_____________________________________________________________________
are true copies of the originals.

He/she hereby encloses:
	a photocopy of an identity document.

In accordance with Legislative Decree DL no. 196/03, the University of Padua is hereby authorised to handle any personal information included with this present application for the purposes of the selection announcement and any future entering into and management of the relationship with the aforesaid University. 

Date,
									Signature