To Magnifico Rettore
Università Politecnica delle Marche
P.zza Roma 22 – 60121 Ancona

SCHOLARSHIP PAYMENT AND NATIONAL INSURANCE CONTRIBUTION

I, the undersigned, (surname and name)_________________________________ born in ____________________ on (date) __________ living in __________________ address __________________________________________ n. ______   ZIP code _____________________

Address for all the communications (to state only if different from the one of residence):

Address_________________ n.________ ZIP code ________________   Municipality _______________________
Telephone number _______________________________   e-mail ______________________________________ 
Fiscal code (compulsory) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|,  
with reference to the scholarship for PhD in _______________________________________________________ 
Cycle XXXVI - Curriculum ______________________________________________________________________”:
1)  for the purposes of application of INPS contribution referred to in art. 2, par. 26, of Law of 8.08.1995, no. 335, declares:
o	I have a social security cover and I am registered at Social Security of _______________________;
o	I have not registered a compulsory social security cover;
o	I am registered at INPS (Gestione Separata Lavoro Autonomo).
2)  for collecting the scholarship:
o	I request that the payment will be credited to the 
Bank Account n. |__|__|__|__|__|__|__|__|__|__|__|__|
          	Bank name/ Prepaid card ____________________________________________________________
          	Branch of ___________________________________________ Branch n. _____________________
          	Address: __________________________________________________________________________
          	ABI Code____________________ CAB Code____________________ CIN____________________ 
           	IBAN Code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
I, the undersigned, agree to promptly notify the University Administration of any change in the circumstances attested to in this declaration, as to ensure a correct application of the social security contributions (Gestione Separata Lavoro Autonomo). I am also aware that Università Politecnica delle Marche shall not be held liable for any problems resulting from delayed notifications thereof.
Date, 							SIGNATURE__________________________________
I, the undersigned declare to have read the disclosure pursuant the D.Lgs. n^ 196 of 30.06.2003 and the EU Regulation 2016/679 (GDPR) of 27.04.2016 in the University site at the link http://www.univpm.it/Entra/Privacy/L/1 – “Disclosure made for the processing of personal data of the students enrolled in the courses at Università Politecnica delle Marche”.		
Date, 							SIGNATURE__________________________________