TO THE HEAD OF DEPARTMENT OF PHARMACEUTICAL AND
PHARMACOLOGICAL SCIENCES

The undersigned

Surname 	Name	Italina Taxpayer code	

		
Date of birth	Place of birth	Province or Country	

		
Permanent Residence	City / Town	Province or Country of Residence	

		
Zip code	Talephone	e-mail	

Address for correspondence (if different)	City / Town	Province or Country of Residence	

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asks

To be admitted to the following public selection, based on qualification and oral examination, for the assignment of a research grant for activity entitld “Adaptable Non-Covalent Antibody Drug Conjugates for Therapy and Diagnosis” for the duration of 1 year at the University of Padova – Department of Pharmaceutical and Pharmacological Sciences

In accordance with art.s 46 and 47 of D.P.R. n 445 of December 28th, 2000, (“Unique text of laws and regulations concerning administrative documentation”)

DECLARES, UNDER HIS/HER OWN RESPONSIBILITY

A)	to have obtained:
 degree (with a course duration of not less than 4 years, as referred to in the pre-existing academic regulations pursuant to D.M. n. 509/1999) in:
 post-graduate degree (pursuant to D.M. n. 509/1999 and to n. 270/2004) in:	

Academic year					/					Session			/			/						
																												
Grade				/					with honours				
																												
Thesis title																								

																												

																												
																												
Supervisor																								
																												
University																								

																												
Faculty																								

B) to have obtain a PhD degree in:	

																												

Academic year					/					Session			/			/						
																												
Thesis title																								

																												

																												
																												
Coordinator																								
																												
University																								

																												
																												
C) REQUEST THAT THE FOLLOWING QUALIFICATIONS AWARDED ABROAD BE VALIDATED FOR THE SOLE PURPOSES OF THE SELECTION PROCEDURE AND ATTACH THE DOCUMENTS REFERRED TO IN  ART. 4 – COMMA 5 – LETT. C)	
	
D) to   be   -    have been 
holder of research grant on :	

																												

																												
																												
	from			/			/					to			/			/								

University / Institution 																						

																												
scientific disciplinary sector								

																												
																												
E) TO BE IN POSSESSION OF THE FOLLOWING FURTHER QUALIFICATIONS: (DETAIL THE QUALIFICATIONS DEEMED RELEVANT FOR VALIDATION APPRAISAL, ALSO PROVIDING FULL DETAILS OF DOCUMENTS TO ALLOW SELF CERTIFICATIONS TO BE CHECKED 	

																												

																												

																												

																												

																												

																												

F) TO BE SUFFERING FROM THE FOLLOWING  DISABILITY AND REQUIRE THE SUPPORT OF:	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	
																												
G) to be able to attend the language test during the oral examination in the foreign language indicated in the public selection announcement (indicate the language):	

																												
																												
H) to have intention to participate in the following research program:	
																												
Title																								

																												

																												

																												

																												
																												
tutor																					
																												
        scientific disciplinary sector															
																												
Department/Research Centre in which the research is carried out																			

																												

																												
I) to be an employee on the following public administration:	

																												

																												

J) to not exceed a maximum period of twelve years, even non continuous, considering  the total duration of the contracts referred to in art. 22 (research grants) and art. 24 (fixed-term Researchers) of Law 240 of December 30th, 2010, also considering contracts with other universities and/or with other institutions listed in the Art. 22 comma 1 Law n. 240/2010, and the duration of the contract referred to in this selection announcement;	
K) to be aware that the University administration does not have any responsibility for missed communications due to wrong information concerning permanent address or contacts, or due to belated or missing notice about variation of  the above-mentioned addresses, nor of any postal or telegraphic errors due to third party or to unforeseen and fortuitous events;	
L) to communicate immediately, trough registered letter with signed return receipt, any change of residence or contact information occurring after the presentation of the application form;	
M) to be aware of the penal sanction in case of false statement, in accordance with Art.76 of the  DPR (Italian law)   445 of December 28th, 2000;	
N) to be aware of art. 75 of DPR 445 of December 28th, 2000 about the loss of benefits related to the assignment if, after a check, the Administration discovers the untruthfulness of the aforesaid declarations;	
O) to allow the University of Pavia to use collected personal data for the selection purposes and for the research grant assignment procedure, in accordance with the D. LGS (Italian Law) n.196, June 30th, 2003 “Legislation concerning the protection of personal data”;	
P) to have read carefully the norms contained in the call for application;
	
Q) to attach the following documents:	
																												
1.	A signed and dated scientific curriculum;	
																												
2.	List of the scientific publications, detailed description according to the international rules, including all authors;	
																												
3.	The publications referred to in art. 4 – comma 11 – lett. c) of the call for applications;	
																												
4.	The documents referred to in art. 4 – comma 5 – lett. c) of the call for applications, regarding the validation declaration – for this competition only – of the academic qualifications awarded overseas;	
																												
5.	The research project regarding the topic;	
																												
6.	Photocopy of a current ID card.	

																												

																												
																												
date			/			/					signature