MASTER COURSE ENROLMENT FORM 
Academic Year 2017/2018

Please sign an ID photo on the right-front side and glue it here

	to the Magnifico Rettore
of the 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

	

		
	REGISTRATION N.
	THE UNDERSIGNED

Code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
- Surname and name	|______________________________________________________________________|

M

F

gender	  born on	  |__|__| |__|__| |__|__|__|__|	 in	|____________________________________________|
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 |__|__|__|__|__|__|__|
APPLIES to be enrolled 
for the Academic Year 2017/2018 
to the 2nd level Master course in Pediatric Endocrinology and Diabetes 

FOR THIS PURPOSE DECLARES 

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 all the original copies of the academic certificates improved by the Italian Diplomatic Authority or Consulate competent for the territory, translated, authenticated, legalized and provided of the declaration of value) and send it to: Università degli Studi di Firenze, Ufficio Post-Laurea NIC - Largo Brambilla, 3 - 50134 Firenze, Italia. 
Please write on the envelop “Enrolment form - Master in Pediatric Endocrinology and Diabetes".

APPLIES, finally
to be admitted to sit for the examination sessions and to complete a traineeship under the rules of the Master establishing decree. 

Disclosure and dissemination of Personal Data
As laid out in the Art. 11 of the University of Florence Personal Data protection Regulation and the art. 7 of the D.L.gs 30/6/2003 n. 196, I authorise the disclosure and dissemination of my personal data, also by publication on the University website and to public or private organizations which may request them for orientation, learning and placement purposes:

	_________________________________	_________________________________________
	(date)	(signature)

Attachments:
	1 additional ID photo signed on the right-front side
	
      copy of a valid identity card

original copies of the academic certificates improved by the Italian Diplomatic Authority or Consulate competent for the territory, translated, authenticated, legalized and provided of the declaration of value.
		other documents (please specify)____________________________________________________________________
	___________________________________________________________________________________________________