Facsimile of application form 
To the Director of the Department of Molecular Medicine 
at the University of Padova

The undersigned____________________________________________________________________
born in __________________________________________________________________[insert city, country]  on__________________, resident in _____[insert ZIP code, city/town, country], ________________________________________________________________ [insert street name and street number],
of _________________________nationality, having telephone no.  _________________________, e-mail _______________________and certified e-mail (PEC): ______________________________

HEREBY REQUESTS
to be admitted to the following selection process for the awarding of a research fellowship titled “…………………………….”, through the evaluation of qualifications and interview process.
The selection process has been authorized by provision of Record no. ……… dated ….

HEREBY DECLARES
aware of criminal liability in the event of false or incomplete statements, pursuant to Italian Presidential Decree 445/2000:
•	to possess the following qualifications:
 _____________________________________________________________________________
•	to be a citizen of  _____________________ [if not an European Union citizen and present on Italian territory: declares to have a valid residence permit on the date of the application deadline];
•	to have read the University's "Regulations Governing Research Fellowships" and to not be in any condition that provides for ineligibility, and not to have family or kinship relationships up to the fourth degree with lecturers or researchers working at the Department elected as "Research Base", or with Rector, or Director General, or a member of the University Board of Governors;

•	to carry out the following work activities at the moment:
___________________________________________________________________________
•	to give their address for the managing of the selection process:
o	Home Address
o	to the following address:
______ [house number], __________________________________________ [street], __________________________________________[city], __________________________________________[country] _______________________________________________ [postcode]

Pursuant to Art. 20 of Law no.104/1992, the applicant requires the following arrangements for interview process ________________________________________________________________________________ and attaches relevant disability certification.  

Declares to be aware and consents that the data provided in this declaration can be treated in compliance with Legislative Decree no. 196/2003 and subsequent amendments and modifications, for all matters relating to managing of this selection process.

The application shall be accompanied by the following:
a) a CV detailing professional, academic and research background;  
b) copy of an identity document;
c) any other documentation as indicated in the selection announcement;
d) any other documentation deemed relevant for the evaluation. 

Date__________________________
Applicant's signature
________________________________________________

As laid down in the Selection Announcement, the undersigned declares to participate at the interview by Zoom Meeting Platform and ensures the building from where s/he will be conducting the interview has the necessary electronic workstation fitted out with the necessary IT and communication equipment (e.g. PC, internet access, video conferencing tools and software, headphones, microphones (specify any other equipment required). 
The candidate declares the video conferencing will take place at the following address: ________________________________________________________(address).

Date__________________________
Applicant's signature
________________________________________________