TO THE HEAD OF THE DEPARTMENT OF
HISTORICAL AND GEOGRAPHIC SCIENCES AND THE ANCIENT WORLD – UNIVERSITY OF PADOVA

TO THE DIRECTORS OF THE ROYAL HOLLOWAY UNIVERSITY OF LONDON CENTRE FOR THE GEOHUMANITIES

The undersigned

Surname	Name	

		
Date of birth	Place of birth	Province or Country of birth 	

		
Residence address	Municipality	Province or Country of fixed residence 	

		
Post code	Telephone no.	Email address	

Domicile address	Municipality	Province or Country of domicile address 	

Post code	Telephone no.	Email address	

VAT number	Tax Code	

As a Creative Commission’s member consisting of:

Title (e.g. Mrs, Dr, ) __________________________________________

Title (e.g. Mrs, Dr, ) __________________________________________

…..

Title of the project: ____________________________________________________________

hereby requests

to be admitted to the public selection procedure for the funding of up to four (4) GeoHumanities Creative Commissions on the theme of ‘Variations on Mobility’.

For this purpose,

in accordance with Art. 46 and 47 of Presidential Decree DPR no. 445 dated 28 December 2000 and being aware of the administrative and criminal penalties laid down by Art. 75 (Loss of Benefits) and Art. 76 (Criminal Proceedings) in the event of forgery in deeds and false declarations, 

He/She hereby declares that

1. he/she has read, understood, and hereby agrees to be bound by the provisions of the selection announcement;

2. the project presented is an original creation and no part of it is subject to copyright;

3. there are no causes that make it impossible to contract with the Public Administration;

4. he/she authorizes University of Padova and Royal Holloway University of London, in accordance with EU General Data Protection Regulation (GDPR, 27.04.2016 no. 679), to use his/her personal data for institutional purposes and necessary for the completion of this selection procedure;

5. the information submitted is true and that he/she is aware of the administrative and criminal penalties should he/she submit forged documents or make false declarations.

He/She also declares

that he/she participates as

 a creative practitioner
 an early stage researcher

He/She hereby encloses

•	a photocopy of an identity document;

•	all the documents required for the Selection Procedure (see Article 4 – Required Documents)

Date,

Signature 

__________________________________