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“Nicola Bruti Liberati”– Year 2015
International Scholarship Application Form
Deadline February 1st, 2016
Politecnico di Milano
Dipartimento di Matematica
Piazza Leonardo da Vinci 32
20133 Milano
ITALY
I, the undersigned Mr./Ms. 1 …………………………………………….........................................................................................................
Surname
Name
Born in ……………………………….………………...……….… State ………………….……………….… on ………………………………
dd / mm / yyyy
Home address ………………………………………….……………………………………………...… No ……….. ZIP code ………………
City ………………………………………………………………………………….……………... (State ……………………………………… )
Personal tax No or Social Security No …………………………..................................................................................................................
Citizenship ……………...……………………..............................................................................................................................................
Ph.D. in ………………………..........................................................……………….…………………………………………… obtained at
the University …………………………………………..……………………………………………………… on ……………………………….
dd / mm / yyyy
ASK
to be admitted to participate in the evaluation procedure for the assignment of the scholarship «Nicola Bruti Liberati – Year 2015,
issued by the Department of Mathematics - Head of Department's Decree Rep. No. 1719/2015, Prot. No 63646 registered on
September 29, 2015
Contact information
City ……………..………………………………………………………………. (State ………………………………………………….……… )
Home address ..………………….……………………………………………...… No ..…..………….. ZIP code ………….…………………
telephone …………..……………………............ e-mail ……………………………………………………….…….…………………………..
Mobile phone ………………………………………
I undertake to promptly communicate any possible change of my own residence or contact details.
Attachments
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copy of the Ph.D. thesis;
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copy of the Ph.D. Degree Certificate;
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curriculum vitae;
‐
No ……… reference letter/s from a professor or from a recognized expert in the field;
‐
any other documentation deemed necessary by the applicant for the evaluation Commission;
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photocopy of the passport or of the identity card;
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a list of all the documents submitted.
Aware of the penal sanctions foreseen in case of false declarations as established by art. 76 of Presidential Decree 445/2000
DECLARES:
- not to be spouse, relative or kin up to and including the fourth degree, of:
- the teaching staff of the Department which has issued this notice;
- the Rector of the Politecnico di Milano
- the General Director of the Politecnico di Milano
- members of the Board of Directors of the Politecnico di Milano.
- the information provided in this application is true and correct to the best of my knowledge and that the signature below is my signature.
I agree to my personal data being processed, in compliance with the Italian Personal Data Protection Code (Legislative Decree no. 196/03) and its
amendments and additions, for purposes related to this evaluation procedure.
Place and date …………………………….………….
dd / mm / yyyy
………………………………………….
(signature)
1
Please write legibly and complete all required fields
ANNEX A SELF‐CERTIFICATION (DECLARATION IN LIEU OF CERTIFICATION AND/OR NOTARIAL DEED ‐ ARTICLES 46 AND 47 OF D.P.R no. 445 dated 28.12.2000) I, the undersigned, Name Born in Resident in City/town, province, country Surname Place of birth (City/town, province, country)
Address, post code aware of the legal consequences of making untruthful declarations or producing or using false deeds under art. 76 of Presidential Decree no. 445 dated 28 December 2000, and the additional sanction under art. 75 of the above‐
mentioned Presidential Decree no. 445 dated 28 December 2000, consisting of forfeiture of any benefits resulting from provisions issued on the basis of untruthful declarations, DECLARE THAT I HAVE THE FOLLOWING ADDITIONAL QUALIFICATIONS (that are not the ones listed in the application form) 1. _________________________________________________________________________________________
_________________________________________________________________________________________ 2. _________________________________________________________________________________________
_________________________________________________________________________________________ 3. _________________________________________________________________________________________
_________________________________________________________________________________________ 4. _________________________________________________________________________________________
_________________________________________________________________________________________ PLEASE SUPPLY, FOR EACH QUALIFICATION, ALL THE RELEVANT INFORMATION ON TIME PERIODS AND SUBJECTS I ALSO DECLARE THAT I have been informed, pursuant to and in accordance with Legislative Decree no. 196 issued on 30 June 2003, that personal information obtained on me will be used, also through computer processing, exclusively for the purposes of the procedure for which this declaration is presented. Date ___________________________ Signature __________________________ ANNEX B SELF‐CERTIFICATION (DECLARATION IN LIEU OF NOTARIAL DEED ‐ ART. 47 of D.P.R no. 445 dated 28.12.2000) I, the undersigned, Name Born in Surname Place of birth (City/town, province, country)
City/town, province, country Address, post code Resident in aware of the penal sanctions consequent upon making untruthful declarations or upon producing or using false deeds under art. 763 of Presidential Decree No. 445 dated 28 December 2000, and the additional sanction under art. 754 of the above‐mentioned Presidential Decree no. 445 dated 28 December 2000, consisting of forfeiture of any benefits resulting from provisions issued on the basis of untruthful declarations, I HEREBY DECLARE that the copies of my publications/scientific products (I’m author or co‐author) annexed to the application, are true copies of the originals: 1. _________________________________________________________________________________________
_________________________________________________________________________________________ 2. _________________________________________________________________________________________
_________________________________________________________________________________________ 3. _________________________________________________________________________________________
_________________________________________________________________________________________ 4. _________________________________________________________________________________________
_________________________________________________________________________________________ 5. _________________________________________________________________________________________
_________________________________________________________________________________________ APPLICANTS SHOULD MARK ALL PUBLICATIONS WITH A NUMBER AND LIST THEM BELOW, STATING: • ONLINE PUBLICATIONS/SCIENTIFIC PRODUCTS: name and surname of the author, title, web site, publication date; • FOR THESES: thesis title, supervisor, university, country, academic year; • FOR BOOKS: name and surname of the author (and any co‐authors), title of the book, place of publication, publisher/series, year; • FOR CHAPTERS IN BOOKS, ESSAYS IN COLLECTANEA ETC.: name and surname of the author of the chapter/essay, title of the chapter/essay, title of the book or other work the chapter is included in, name and surname of coauthor(s), place of publication, publisher, year, number of the first and last page; • FOR ARTICLES IN MAGAZINES: name and surname of the author (and any co‐authors), title of the article, title of the magazine it is in, number, day/month/year, place of publication, publisher, number of the first and last page; • FOR CONFERENCE PROCEEDINGS: name and surname of the authors of the proceedings, title of the contribution and name of the conference, meeting/conference proceedings, city/town, day/month/year, (edited by) name and surname of the editor, place of publication, publisher, year, number of the first and last page; • FOR EDITORSHIPS: title of the work, name of the editor (edited by), place of publication, publisher/series, year; • FOR OTHER KINDS OF PUBLICATIONS/SCIENTIFIC PRODUCTS: state the name and surname of the author/coauthor(s), year, and all the information required to identify them. SCIENTIFIC PUBLICATIONS PUBLISHED ON ONLINE JOURNALS ARE CONSIDERED ORIGINALS IF THE APPLICANT PROVIDES THE RELEVANT WEB SITE ADDRESS. PUBLICATIONS MUST BE ANNEXED FOR ASSESSMENT PURPOSES. I ALSO DECLARE THAT I have been informed, pursuant to and in accordance with Legislative Decree no. 196 dated 30.06.03, that personal information obtained on me will be used, also through computer processing, exclusively for the purposes of the procedure for which this declaration is presented. Date ___________________________ Signature __________________________ Presidential Decree no. 445 dated 28 December 2000, published in the Ordinary Section of Official Gazette issue no. 42 dated 20 February 2001. Consolidated act of the legislative and regulatory provisions regarding administrative documentation. Art. 46 Declarations in lieu of certification 1. The following statuses, personal qualities and events may be demonstrated by a declaration, which may be made on request, signed by the party concerned and produced instead of regular certification: a) date and place of birth; b) residence; c) citizenship; d) possession of civil and political rights; e) marital status; f) family status; g) declaration that the person is living; h) birth of son or daughter, death of spouse, parent, son or daughter; i) registration in professional associations, rolls or lists held by public administration; l) membership in professional orders; m) educational qualifications, examinations taken; n) professional qualifications, specialised educational qualifications, licences to practice, training, professional development and technical qualification courses; o) income or economic situation, also for the purposes of granting benefits of any kind under special legislation; p) fulfilment of specific tax obligations, indicating the amount paid; q) possession and number of tax code, VAT number, or any other item of information present in tax records; f) status of unemployment; s) status of retiree and pension category; t) status of student; u) status of legal representative of physical persons or corporate entities, of guardian, liquidator, and similar statuses; v) registration in associations or societies of all kinds; z) all circumstances pertaining to the fulfilment of obligations for national service, including those certified in the document demonstrating the status of service; aa) that the applicant is not the subject of any penal sentences or orders for the application of preventive measures, civil decisions and administrative measures entered in the criminal records office under current legislation; bb) that the applicant is not aware of being subject to penal proceedings; bb‐bis) that the applicant is not the subject of court orders that apply the administrative sanctions listed in Lgs. D. no. 231 issued on 8 June 2001; cc) status of dependent; dd) all information of which the person involved may be aware which is contained in civil status registries; ee) that he/she is not in a condition of receivership or bankruptcy and has not presented a request for arrangement with creditors. Art. 47 ‐ Declaration in lieu of a notarial deed 1. Notarial deeds concerning status, personal qualities or events of which the person involved is directly aware may be replaced by declarations made and signed by the person involved in compliance with article 38. 2. Declarations made in the interests of the person making them may also regard status, personal qualities and events pertaining to other parties whom the person making the declaration is personally acquainted 3. With the exceptions expressly permitted by law, in relations with public authorities and with parties providing public services, all statuses, personal qualities and events not expressly indicated in article 46 may be demonstrated by the person involved by presentation of a declaration in lieu of notarial deed 4. Except where the law expressly states that loss must be reported to the police in order to begin administrative proceedings for issuing a duplicate identity document or other document certifying a person’s status and personal qualities, loss of such a document shall be demonstrated by the person requesting the duplicate in the form of a declaration in lieu of notarial deed. Art. 76 Penal legislation. 1. Anyone who makes an untruthful declaration and produces or uses false documents in the circumstances identified in this act shall be punished under the penal code and applicable special legislation. 2. Exhibiting a deed containing information which is no longer true is equivalent to using a false document. 3. Declarations in lieu of notarial deed made under articles 46 and 47 and declarations made on behalf of the people identified in article 4, paragraph 2, shall be considered made before public officials. 4. If the offences identified in paragraphs 1, 2 and 3 are committed to obtain appointment to public office or the authorisation to exercise a profession or an art, the judge may, in serious cases, apply temporary interdiction from public office or from the profession or art. Art. 75 Forfeiture of benefits. 1. The provisions of article 76 notwithstanding, if a control of the type identified in article 71 should reveal that the content of the declaration is untruthful, the person making the declaration shall forfeit any benefits that may be consequent upon the order made on the basis of the untruthful declaration. Art. 38 Methods for submitting and signing applications. 1. All applications and declarations to be presented to public authorities or to operators of public services may be sent by fax or e‐mail. 2. The applications and declarations sent via e‐mail, including applications for participation in selections aimed at employment (of any kind) in public administration, or for registration in professional associations, registers or rolls held by public administrations are valid if performed in accordance with art. 65 of Lgs. D. no. 82 issued on 7 March 2005. 3. Applications and declarations in lieu of notarial deed to be produced before public authorities or operators of public services shall be signed by the person named in them in the presence of an employee or signed and presented with an uncertified photocopy of the signatory's identity document. The photocopy of the document will be enclosed in the file. Applications signed by the applicant and photocopies of identity documents may be sent by email; in proceedings for the award of public contracts, this option is permitted within the limits set by the regulations contained in article 15, paragraph 2 of law no. 59 dated March 15 1997. 3‐bis. The power of representation for the creation and submission of requests, projects, statements and other certifications, as well as the collection of deeds and documents from public authorities or operators of public services can be validly conferred to another subject in the ways set forth in this article.