Corsi di perfezionamento di studi musicali

s t u d i e s
m u s i c a l
Modulo per la
domanda di ammissione
Application form
for admission

i n
Informativa ai sensi del D.Lgs. 196/03
Codice in materia di protezione dei
dati personali
c o u r s e s

Information concerning data privacy (Law 196/03)

Formula per il consenso al trattamento

dei propri dati personali
Statement of consent
to the handling of personal data

Cittadini extra UE
S p e c i a l i z a t i o n

Non-EU citizens

Anno Accademico
Academic Year

2005
2006
 AMMISSIONE
Spett.le FONDAZIONE
ACCADEMIA NAZIONALE DI SANTA CECILIA
Via Vittoria, n. 6 - 00187 Roma
Fax +39 06 32817366

Il/la sottoscritto/a (I the undersigned)...................................................

........................................................................................................................

chiede di essere ammesso/a in qualit di allievo/a al Corso di

DI

perfezionamento di (wish to apply for admission as student of the

Specialization Course in)............................................................................

DOMANDA

........................................................................................................................

che si terr presso codesta Accademia nellAnno Accademico

2005/2006 (to be held at the Accademia in the Academic Year

2005/2006).

A tal fine, sotto la propria responsabilit, il/la sottoscritto/a di-

chiara (To this end, and on my own responsibility, I state):

1. di essere nato/a (place of birth) ...........................................................

........................................................................................................................

il (date of birth) ............................................................................................

2. di essere residente nel comune di (resident at) .............................

............................................................................................(prov. ................)

Via/P.zza (Street/Sq.) .................................................................................

.............................................. n............... cap (post code)..........................

tel. (phone)...................................................................................................
fax ................................................ e-mail. ...................................................

3. di essere cittadino/a (nationality) .......................................................

4. di essere in possesso del diploma in (diploma in) .........................

........................................................................................................................

conseguito presso il (awarded by / institution)......................................

........................................................................................................................
5. di accettare, senza riserve, le condizioni previste dal bando di

FORM
ammissione con le relative norme generali e il giudizio inappel-
labile della Commissione desame (I declare that I unreservedly
accept the conditions laid down in this announcement and in particu-
lar those of the general regulations, and the decision, which shall be

APPLICATION
final, of the Board of Examiners)

6. di desiderare che tutte le comunicazioni relative alla presente

domanda siano inviate al seguente indirizzo (please send all
communications relating to this application to the following address):
........................................................................................................................
........................................................................................................................
........................................................................................................................

Il/la sottoscritto/a allega (I attach):

a. Certificato di diploma in (Diploma certificate in) ..........................
........................................................................................................................

b. Curriculum artistico (artistic curriculum)

c. Programma desame (examination program)
d. Ricevuta del versamento postale o bancario di 42,00.
(Receipt of payment on postal or bank account of 42,00).

Data (Date).................................................

FIRMA (SIGNATURE)
........................................................................

CITTADINI EXTRA UE / NON-EU CITIZENS

I cittadini extra UE, durante la frequenza dei corsi, ivi compreso il periodo
di partecipazione agli esami di ammissione, conferma e diploma, devono es-
sere in regola con le norme vigenti in Italia in materia di Pubblica Sicurezza.
Non-Eu citizens must comply with police regulations currently in force in
Italy during the whole period of attendance at courses, including the pe-
riods of participation in admission, end-of-year and diploma examinations.

FIRMA PER PRESA VISIONE

(Signature attesting that the above
information has been read and understood)

.................................................................