Application Form for the Pitagora Mundus Scholarships

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    The personal data will be handled exclusively by our office according to Italian law of privacy (Law 675/96)

    NAME:
                        SURNAME:
    BORN IN:
                        DATE OF BIRTH:
    NATIONALITY:
                        PASSAPORT N.:
    ADDRESS:
                        POSTAL CODE:
    CITY:
                        PROVINCE:
    NATION:
                        PROFESSION:
    HOME PHONE:
                        MOBILE:
    FOOD DEMANDS:
                        ALLERGIES OR PATHOLOGIES:

    sex:

    email:

    confirm email:

    knowledge of the Italian language

    CONTACT IN CASE OF EMERGENCY

    Name:
                        Surname:
    Telephone:
                        Mobile Phone number:
    email:
                        Relationship (ad es: father, mother, sister):

    CONTACT ISCAPI COUNTRY (IF ANY)

    Name:
                        Surname:
    Telefono:
                        email:

    Request scholarship. Registration for the course of the month of:

    DESTINATION AND TYPE OF ACCOMODATION

    Borgo di Belvedere Marittimo - Borgo di Cosenza; Accommodation with shared room (in apartment)

    Borgo di Santa Severina; Accommodation with Shared room (in Convitto)

    single room (only in apartments): + 8 Euro a notte.

    Declare I have read the terms and general conditions and accept them.

    I authorize the processing of my personal data in accordance with art. 13 of the Italian Law n.196 / 2003 (To send the registration request is necessary to authorize the use of data)