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									     Doc. code 025                                                        Application entran ce examination 1st Level Degree


                                       TO THE MAGNIFICIENT RECTOR
                                               UNIVERSITY OF PERUGIA


The undersigned _________________________________________________________________________
                             surname                                                            name
born in__________________________________________ country_________________________________

date of birth____________ residence _____________________________(_______) postal code__________

address______________________________________________ n.___________

domiciled for the at present for the entrance examination in________________________________________

postal code__________ address______________________________________________ n.______________

telephone numbers________________________________________________________________________

tax code_____________________________________________

aware of the previewed penalties in case of false declarations and of the loss of the eventually obtained benefits (art. 75
and 76 D.P.R. n. 445 of 28/12/2000)

                                                       DECLARES

-to be in possession of the school-leaving certificate______________________________________________

                                                                                 ______/100 ( _______________ )
obtained in the academic year__________________                mark:
                                                                                 _______/60 ( _______________ )

at the institute____________________________________________________________________________
                                              (name and address of the school)

                                                      REQUESTS
for the Academic Year 200…./… to be allowed to take part to the selective entrance examination for the degree course:

_____ ”JOB CREATION ORIENTED BIOTECHNOLOGY” International First Level Degree ____________

The undersigned declares to have looked at the date, seat and procedure of the entrance examination, and also at
the exclusion reasons published in the notice of the course. Furthermore he/she declares to be aware that no
communication will be given on this matter.

He/she also declares to be aware that, in conformity with art. 13 of D.L.vo 30 june 2003, n. 196 “Codice in
materia di protezione dei dati personali”, his/her personal data will be used by University of Perugia only for
institutional purposes, in the observance of the provisions in force.

Perugia………………                                                  Signature(1)…………:………………………………

                          Stamp and signature of the accepting officer______________________________________

(1) the signing of this declaration from the undersigned in presence of the accepting officer does not require the
authentication (art. 38 of D.P.R. 28/12/2000 n. 445), but it is followed by the signature and stamp of the accepting
officer. The signing can be done in absence of the accepting officer under presentation of a copy of a valid
document of identification.

Attachments:
a) Receipt of the bulletin post office account n° 8052 in the name of: Banca dell’Umbria-Gruppo Unicredit, of
Euro 50,00, as contribution for general expenses for the admission to the course (available at the main
Secretariat of Medicina) and clear copy of an identification document (passport is better).

								
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