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national award info 2

National Arts Award

VIII EDITION 2010/2011

FORM

Name Name and

Date and place of birth

Nationality and domicile

Home Phone

Fax

Mobile

E-mail

Title:

Year:

Size / Duration (in case of video works / video installations):

Description of work:

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Affiliation:

Teacher contact:

E-mail:

Phone:

academic course attended ( name and course level):

Year of study:

declare that I agree with the rules of the competition notice

Signature:

Stamp of membership and signed by the director

Information about the article. 13 of Legislative Decree no. 196/2003: The above data will be used

exclusively within the institutional activities of the National Arts Award, the holder of

treatment. The person have the rights set out in Article. 7 of Legislative Decree no. 196/2003. The registrant

criminally liable for false statements (Article 76, DPR 28 December 2000, n. 445). The registrant

forfeit any benefits arising on the basis of false declarations

false (art. 75 DPR 28 December 2000, n. 445).

Place and date Signature

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