“Giuseppe Sciacca” Award - Premio Internazionale Giuseppe Sciacca
“Giuseppe Sciacca” Award - Premio Internazionale Giuseppe Sciacca
“Giuseppe Sciacca” Award - Premio Internazionale Giuseppe Sciacca
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- 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 />
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