NAME.........................................................................SURNAME...................................................................

PLACE OF BIRTH......................................................DATE.................................................SEX..................

NATIONALITY...............................................................................................................................................

ADDRESS........................................................................................................................................................

.........................................................................................................................................................................

TELEPHONE..............................................................E-MAIL.......................................................................

MOTHERTONGUE.........................................................................................................................................

LANGUAGES SPOKEN..................................................................................................................................

PRINCIPAL EDUCATION AND WORK EXPERIENCES..............................................................................

.........................................................................................................................................................................

...........................................................................................................................................................................

.........................................................................................................................................................................

.........................................................................................................................................................................

.........................................................................................................................................................................

.........................................................................................................................................................................

.........................................................................................................................................................................

.........................................................................................................................................................................

.........................................................................................................................................................................

.........................................................................................................................................................................

I HERBY APPLY TO BE ADMITTED TO THE UNIDEE IN RESIDENCE INTERNATIONAL PROGRAM

FOR THE YEAR 2003.

FURTHERMORE I HEREBY CONSENT, IN ACCORDANCE WITH ART. 11 OF LAW 675/96 (PROTECTION OF PRIVACY), TO THE GATHERING, PROCESSING AND DIFFUSION OF PERSONAL DATA SOLELY FOR PURPOSES RELATING TO THE PUBLIC AND CULTURAL ACTIVITIES OF THE FONDAZIONE PISTOLETTO ONLUS