APPLICATION FORM

I DATI RICHIESTI DALL’UNIVERSITA’ SONO RACCOLTI IN CONFORMITA’ AL D.LGS. 30 GIUGNO 2003, N. 196

	to the Magnifico Rettore
Università degli Studi di Firenze
Unità Funzionale "Didattica integrata con Servizio Sanitario Regionale e con la Scuola di Scienze della Salute Umana"
Largo Brambilla, 3 - 50134 Firenze

ACADEMIC YEAR 2017/2018

Application form to the selection for the enrolment in
the 2nd level Master course in Pediatric Endocrinology and Diabetes

THE UNDERSIGNED
Surname and Name   _______________________________________________________________________________________________________________|

M

F

Gender                  born on |__|__| |__|__| |__|__|__|__| in (city)  _______________________________________________________| 
Nation _______________________________| Nationality________________________________________|
resident in 
(street/square)__________________________________________________________________________| n.________| City ________________________________________________________________________|
Nation___________________________________________________| local zip code |__|__|__|__|__|__|__|
Telephone number ______________________________________|  
Mobile number__________________________________________| e-mail (please write in BLOCK CAPITALS)   ______________________________________________________________________________________|
address (if different from residency)
(street/square)__________________________________________________________________________| 
n.________| City ________________________________________________________________________|
Nation___________________________________________________| local zip code |__|__|__|__|__|__|__|
telephone/mobile number __________________________________________________________________| 
APPLIES to be admitted to the selection for the enrolment and
FOR THIS PURPOSE DECLARES ON HIS/HER SOLE RESPONSIBILITY

To have the following academic qualifications:

•	Bachelor’s Degree in __________________________________________________________________________________|
from the University of   ________________________________________________________________________________|
awarded on  |__|__| |__|__| |__|__|__|__|    with a final mark of |__|__|__|__|__|__|
•	Master’s Degree in ____________________________________________________________________________________| 
     from the University of   ________________________________________________________________________________|
     awarded on  |__|__| |__|__| |__|__|__|__|    with a final mark of |__|__|__|__|__|__|
•	PhD in ________________________________________________________________________________________________|
      from the University of   ________________________________________________________________________________|
      awarded on  |__|__| |__|__| |__|__|__|__|    with a final mark of |__|__|__|__|__|__|
•	Post-Graduate Degree in / Medical Specialty in________________________________________________________|
      from the University of   ________________________________________________________________________________|
      awarded on  |__|__| |__|__| |__|__|__|__|    with a final mark of |__|__|__|__|__|__|
•	other (please specify)__________________________________________________________________________________|
 (please attach a description of the mark system in your country).
.  To have the following credentials which he/she calls for consideration (certificates, publications, others) |__________________________________________________________________________________________________________|
|__________________________________________________________________________________________________________|
        .  to have the following linguistic skills: 
|__________________________________________________________________________________________________________||__________________________________________________________________________________________________________|
        . to have the following informatics skills: 
	   |__________________________________________________________________________________________________________|
         |__________________________________________________________________________________________________________|

		  . that he/she is aware of the regulations and deadlines provided for the competition notice. In particular that this application form will be accepted only if it will reach the email address didatticamaster-bio@unifi.it by the deadline set on 30th of March 2018. 

	   . that he/she is aware that the only valid document for legal purposes is the official decree signed by the Rector of the University of Florence.

	   . that he/she is aware that in case of misleading declarations, without prejudice to the criminal liability, this application form will be excluded from the selection.

	___________________________	_________________________________________
	(date)	(signature)

PLEASE DO NOT FORGET TO ATTACH ALL THE FOLLOWING DOCUMENTS:

	copy of your Academic Qualification Certificates with details of all the passed exams and the marks obtained and the title of the thesis research, translated into English or Italian Language.

 a description of the marks system in your country.

	curriculum vitae (in English or French)

	copy of a valid identity card

	copy of the other credentials listed above (publications, certificates
_______________________________________
_______________________________________
_______________________________________
_______________________________________