Prot. 0003424 <NomeRep> N. del 17/05/2022 [UOR SI000066 Cl. III/12]

ANNEX 1 
APPLICATION FORM 

To 
the Director of the Department of Medicine and Surgery
University of Parma

I, THE UNDERSIGNED,
(Forename(s)) …………………………………. (Surname)………………………………………… 
Place of birth (City/State/Country) ………………………………. 
Date of birth (dd/mm/yy)  …………………………..
Nationality ……………………………
Permanent residence address (number/street/town/postal code/Country: 
………………………………………………………………………………………………………… 
Email address: ……………………..		mobile phone:………………………..
agree to the processing of my personal data, in accordance with Italian Leg. Decree n. 196/2003, for the purposes of the present selection procedure.

I, THE UNDERSIGNED,
having read the Call for award of one research grant entitled: “Assessment of exercise capacity in patients with disabling cardio-pulmonary disease” – Tutor Prof. Alfredo Antonio CHETTA.
REQUEST
to apply for the above mentioned research grant, and to this end, aware that false declarations are punishable by law and that this Administration will carry out random checks on the accuracy of the declarations made by candidates,
DECLARE
under my own responsibility 
- 	that I am Ukrainian Citizen
-	that I hold the following educational qualifications………………………………………………,
awarded by………………………………………………………, Date………………………….;
-	that I have a level of understanding and writing of the English language corresponding to at least a B1;
-	that I have …..…. years of documented experience in in the field of the selected research grant;
-	that I wish to receive any communication relating to the selection at the following address and that I will give due notice of any change of address:
Address (number/street/city /postal code/Country): ……………………………………………..........………………………………………………… 
Email address: ……………………………………………………… 

To be attached to this form:
-	Annex 2 “Curriculum vitae”, signed and dated by the applicant, providing evidence of possession of the skills required to carry out the research;
-	copy of a valid identity document (ID card or passport);
-	any other qualification, working task, research activity at public and private institutions and publications that the applicant deems appropriate to submit.

Date							Signature

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