(must be completed by all E.U. citizens who do NOT have a residence/domicile/dwelling in Italy or whose residence/domicile/dwelling over the last 5 years has NOT been continually in Italy-read information and notes on the back -)

The undersigned ______

born in ______(province) ______on ____/_____/______,

employed by the company ______with headquarters in ______

aware of the criminal penalties in the event of false declarations and the creation or use of false documents (art.76 of the Presidential Decree 445/2000), as well as of the loss of any benefits which may occur if the measure is issued based on false statements (art. 75 of the Presidential Decree 445/2000), in accordance with articles 46 and 47 of the Presidential Decree 445/2000, under their own responsibility, declares (please fill in all the spaces):

[(1)] that they are resident in (Country and city)______at (house number/name and street) ______;

[(1)] that they have a domicile/dwelling in(Country and city)______at (house number/name and street) ______;

that they are a citizen of ______;

(hereafter tick only the applicable boxes below and fill out any relevant items)

□[(2)]that they have not resided/domiciled/lived in countries other than that of their current residence over the last five years;

□[(3)] that they have resided/domiciled/lived in the following countries over the last five years;

1)Country:______City: ______from ______to ______;

2)Country:______City: ______from ______to ______;

3)Country:______City: ______from ______to ______;

□[(4)]in countries other than Italy, where they have a current and/or previous residence/domicile/dwelling, that they have not held, at least during the last five years, any criminal convictions and that they are not the recipient of any judicial/administrative measures entered in the registers of those judicial authorities;

□[(4) ]that they have held, during the last five years, in countries other than Italy, where they have a current and/or previous residence/domicile/dwelling, criminal convictions and that they are the recipient of any judicial/administrative measures(please specify the country, authority and place, court order, reason and date):

1)Country:______Authority:______of(city)______number and date of the court order ______penalty/sanction imposed and reasons______;

2)Country:______Authority:______of(city)______number and date of the court order ______penalty/sanction imposed and reasons______;

3)Country:______Authority:______of(city)______number and date of the court order ______penalty/sanction imposed and reasons______;

□[(4)]for the last 5 years, in countries other than Italy, where they have a current and/or previous residence/domicile/dwelling, that they arenot aware of being subject to any criminal proceedings;

□[(4)]for the last 5 years, in countries other than Italy, where they have a current and/or previous residence/domicile/dwelling, that they are aware of being subject to the following criminal proceeding(s)(please specify the country, procedural authority and place, procedure details, reason and date):

1)Country:______Authority:______of(city)______number and date of the court order ______reason______;

2)Country:______Authority:______of(city)______number and date of the court order ______reason______;

3)Country:______Authority:______of(city)______number and date of the court order ______reason______;

They declare, finally, to be informed pursuant to and in accordance with article 13 of the Italian Legislative Decree no. 196/2003 regarding the fact that the personal data collected will be handled, including with computer tools, exclusively within the procedure for which this declaration is made. To this end, they authorise the handling of their personal data.

Date ______The declarant

______

WARNING:a copy of the declarant's valid identity document needs to be attached to the application.

INFORMATION

This form must be completed in the applicable sections only by EC nationals (including Italians) who do NOT have a residence/domicile/dwelling in Italy or if their residence/domicile/dwelling over the past 5 years has not been continually in Italy. It is necessary, according to the Implementing Regulations (EU) 2015/1998, for personal background checks to be conducted in order to obtain an identity card for Orio al Serio/Bergamo airport.

Any criminal records existing in any of the countries of residence, other than Italy, at least during the last five years, must therefore be indicated. For Italy, this information will be verified at the competent judicial offices by the Border Police Office at Orio al Serio/Bergamo airport.

This form must be sent by the declarant, together with a copy of their valid identity document, via email to the address or deposited directly in the Border Police offices at Orio al Serio/Bergamo airport from Monday to Friday, 8am to 7pm.

Omitting the information and/or providing incomplete information in this form, or the failure to submit it, will not allow the issue of the airport identity card for Orio al Serio/Bergamo airport.

According to article 71 of the Presidential Decree 445/2000, the Border Police at Orio al Serio/Bergamo airport may check with the competent authorities from the Country/Countries indicated regarding the accuracy of the declarations made in this form.

NOTES

1/3

[(1)]residence: indicates the place where a person has their habitual residence, i.e. where they usually live

domicile:is the place where a person has established headquarters for their affairs and interests.

dwelling: indicates the place where a person is located, even if only temporarily.

[(1)]

[(2)]for the purposes of this proceeding, the country of residence/domicile/dwelling is the country in which a person remains permanently for periods equal to or greater than6 months.

[(3)]indicate only the places where you have lived over the last five years for periods equal to or greater than6 months.

[(4)]only criminal convictions, judicial/administrative measures and criminal proceedings need to be mentioned that have existed over the last five years, in all the countries of current and/or previous residence/domicile/dwelling, excluding Italy. For Italy, this information will be verified at the competent judicial offices by the Border Police Office at Orio al Serio/Bergamo airport.

[(4) ]

[(4)]

[(4)]