To the Director of the Department/Centre/… ______________
of Ca’ Foscari University of Venice 
(address of the Department/Centre/…)

I, the undersigned _________________________________________________________________ 
born in (City/Town name)______________________________ (Province/Region of _________, Country ___________) on (date) _______________, passport no. _____________ taxpayer’s code no. (if available) __________________________________ 
resident in (City/Town name) __________________ (Province/Region of _________, Country ___________) in Street/Square/…____________________ (indicate the street/square name) no. _____, postcode _____________, nationality ________________, tel.(national prefix included) __________________ mobile number (national prefix included)  ______________________,   email address___________________________

hereby submit

my application for the public selection based on qualifications, project proposal and interview for the call for applications to shortlist researchers allowed to submit collaborative proposals. 
I, the undersigned, fully aware of the liabilities, including criminal liability, arising from untruthful declarations, pursuant the Italian law (D.P.R. 445/2000), hereby declare that:

a)	My nationality is_______________________;
b)	I am physically fit for the position; 
c)	(Only for non-EU citizens who are already in Italy) I am in possession of Master’s Degree/PhD title…… awarded by(name of the University/Institution)_______________on (date)______________________
d)	(Only for non-EU citizens who are already in Italy) I am in possession of a residence permit  (please, indicate the type of permit)_________ expiring on (date) ________; 
e)	(Only for non-EU citizens who are already in Italy) I am not in possession of any residence permit, and therefore I request its filing, in case of the awarding of the fellowship I am applying for;
f)	I choose English as the language for the interview and any other test;
g)	I request the following benefits established by the Italian Law no. 104/92:
.......................................................................................................................................................
For the above mentioned purpose I enclose disability certification;
h)	I agree and undertake that I shall be bound by and comply with the terms and conditionsof the University Regulations on Intellectual Property, issued by D.R. no. 351/2012 of June 28th 2012 and subsequent additions and amendments,if awarded the research fellowship. 
i)	I agree and undertake that I shall be bound by and comply with the terms and conditions ofthe University Regulations on Research Fellowship awarding, if awarded the research fellowship. 
j)	I agree and undertake that I shall be bound by and comply with the terms and conditions of the Ethical Code of the University;
k)	I agree and undertake that I shall be bound by and comply with the terms and conditions ofthe Public Administration Code of Conduct, in accordance with art. 54 Italian Law D.L.. no. 165 issued onMarch 30th 2001;
l)	I agree and undertake that I shall be bound by and comply with the terms and conditions of the university Regulations.
m)	Furthermore, I undertake to notify any variation with respect to the above listed declarations that may occur before and during the research fellowship duration, if awarded the research fellowship. 

Date									Signature