APPLICATION FORM

(please, send to thin 10 December 2016)

Attn. toSCIENTIFIC COMMITEE OF THE JEAN MONNET CENTRE OF EXCELLENCE

“RIGHT AND SCIENCE”

University of Perugia,Department of Experimental Medicine

Piazzale Gambuli, Building A – Floor 8th, 06132 – Perugia

I, the undersigned (surname and name)______born in ______(province______)on (Date of birthdd/MM/yyyy)______C.F.______residentin ______(province______) streetaddress______postcode/ZIP______

Contactaddresschosen for the purposes of this Call for Applications:

City______(province/district of ______) streetaddress ______postcode/ZIP ______telephonenumber______e-mail address______

HEREBY FORMALLY REQUEST

toparticipate in the selection for the admission ton.4 fellowships for youngResearchers (under 35) to carry out a researchactivityrelated to oneamong the followingfields:

Biobanks

Protection of Personal Data

Genetic information

Freedom of Research and itslimits

with a proposal: (title)______

I declare, under myownresponsibility, in accordance (and for alllegalintents and purposes) with articles 46 and 47 of the D.P.R. (President of the Republic’sDecree) 28.12.2000 no. 445 :

that I am a citizen of ______

 that I have a University Degree in ______awarded on (conferral date dd/mm/yyyy) ______by the University of______;

that I have the title of Ph.D in______awarded on (conferral date dd/mm/yyyy) ______by the University of______;

Furthermore I, the undersigned, include the followingattachments to the application:

theproposalaccording to the format hereinafterdescribed;

acopy of currentlyvalididentitydocument;

curriculum vitae in Europass Form.

I, the undersigned, declare to be aware of the following:

1) That the Centre of Excellence “Rights and Science”assumes no responsibility and shallnot be liable for anypostal or telegraphicdelays or hurdles, force majeure or in anyoccasionarising from an incorrect/missingindication of the address by the applicant or from failure on the candidate’s part to timelyinformthis Centre of anychanges in his/heraddress or othercontact information;

2) Of the penalsanctions in which the undersignedwouldincur in case of false declarations or thosethatcontain data that no longercorrespond to the truth, asforeseen by article 76 of the D.P.R. 28.12.2000, no. 445;

3) Of article 75 of the D.P.R. 28.12.2000, no.445 regarding the relinquishment/loss of any benefits resulting from the actionthatis to be issued in the case that, followingverification, this Centrewere to findproof of false content in the above-mentioneddeclaration;

4) I, the undersigned, according to the D.Lgs. 196/2003 (Code of Regulations on the Protection and Processing of Personal Data) declarethat I amawarethatmy data will be used by the Centre of Excellence “Rights and Science” for institutionalpurposes and in compliance with the principle of pertinence.

______

(Place and date)

______

(Signature)

Format of the Proposal

(Text body: max 2000 Word (includingtables, figures and references)

1. Name and Surname:
2. Title of proposal:
3. Rationale and Background:
4. Problems to be solved:
5. Objectives.
6. Activities.
7. Outcomes.

SIGNING OF THE FORM

I, the undersigned (surname and name)______born in ______(province______) on (Date of birthdd/MM/yyyy)______C.F.______resident in ______(province______) street address______postcode/ZIP______

declare to be aware of the penalsanctions in which the undersignedwouldincur in case of false declarations or thosethatcontain data that no longercorrespond to the truth, asforeseen by article 76 of the D.P.R. 28.12.2000, no. 445.

(Place and date)

______

SIGNATURE

______-

(Signaturewrittento theeffects of art. 38 of PresidentialDecree n. 445/2000 and f.c.)

(Please, attach aphotocopy of Identity Document )

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