16.06.2013 Views

“Giuseppe Sciacca” Award - Premio Internazionale Giuseppe Sciacca

“Giuseppe Sciacca” Award - Premio Internazionale Giuseppe Sciacca

“Giuseppe Sciacca” Award - Premio Internazionale Giuseppe Sciacca

SHOW MORE
SHOW LESS

You also want an ePaper? Increase the reach of your titles

YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.

- ATTACHED A -<br />

Application form<br />

To the International <strong>“<strong>Giuseppe</strong></strong> <strong>Sciacca</strong> “ <strong>Award</strong> 2012<br />

President’s Office - Via Federico Cesi, 44 - 00193 – ROME<br />

Mailing Office Address<br />

Via Tor dè Schiavi, 50 b - 00172 – Rome - Tel. (+39) 06.92594855 - Fax (+39) 06.45423079<br />

Object: Announcement of Competition 2012 – XI Edition.<br />

I, the undersigned * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

( Surname and Name )<br />

Born in *. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . on . . . . . . . . . . . . . . . . .<br />

(Place of birth) (District) (day/month/year))<br />

Resident in * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode* . . . . . . . .<br />

Address *. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

Phone number *. . . . . . . . . . . . . . . . . . . . . Mobile number *. . . . . . . . . . . . . . . . . . . . .<br />

E-mail *. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

Current address where to send the mail if different from the permanent address<br />

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

Qualification *. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

Obtained . . . . . . . . . . . . . . . at the. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

(day/month/year))<br />

of. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

(University, Institute, Polytechnic Institute)<br />

Page 1 of 2

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!