Continua - Università degli Studi del Piemonte Orientale

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ALL. B
SELEZIONE PUBBLICA (PER TITOLI E COLLOQUIO) FINALIZZATA AL CONFERIMENTO DI
DUE INCARICHI DI COLLABORAZIONE COORDINATA E CONTINUATIVA PER
L’ESPLETAMENTO DELLA FUNZIONE DI COORDINATORE DIDATTICO PER IL CORSO DI
MASTER UNIVERSITARIO IN “MEDICINA D’URGENZA E DI AREA CRITICA PER INFERMIERI”
PRESSO LA FACOLTÀ DI MEDICINA, CHIRURGIA E SCIENZE DELLA SALUTE
DELL’UNIVERSITÀ DEGLI STUDI DEL PIEMONTE ORIENTALE – SEDE DI NOVARA.
DICHIARAZIONE SOSTITUTIVA DI CERTIFICAZIONE
(ART. 46 DPR 445/2000)
DICHIARAZIONE SOSTITUTIVA DI ATTO DI NOTORIETA’
(ART. 47 D.P.R. N. 445/2000)
Con riferimento alla domanda di partecipazione per la selezione sopra indicata, il/la sottoscritto/a
............................................................................. nato/a a ..................……….................... (provincia
………….) il ……………………………………, residente in …………………………………………….
(provincia ……….), via/c.so ………………………………….. n. ………………, c.a.p. …………………, ai
sensi degli artt. 46/47 del D.P.R. 445/2000 e consapevole delle sanzioni penali, nel caso di dichiarazioni
mendaci e falsità negli atti, richiamate dall’art. 76 del D.P.R. n. 445/2000
DICHIARA
A) TITOLO DI STUDIO
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B) ESPERIENZE PROFESSIONALI (giudicate attinenti alle mansioni da svolgere):
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TITOLI ACCADEMICI, DIPLOMI O ATTESTATI DI SPECIALIZZAZIONE
QUALIFICAZIONE PERSONALE, RICONDUCIBILI AL PROFILO NECESSARIO:
C) ULTERIORI
E
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D) ESPERIENZE DI COORDINAMENTO MASTER E DI INSEGNAMENTI IN AMBITO UNIVERSITARIO
(giudicate attinenti alle mansioni da svolgere):
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Dichiaro di essere informato, ai sensi e per gli effetti di cui al D. Lgs. n. 196 del 30.06.2003, che i dati
personali raccolti saranno trattati anche con strumenti informatici esclusivamente nell’ambito del
procedimento per il quale la dichiarazione viene resa.
Data __________________________
Firma autografa(*)________________________
(*)Se la dichiarazione è consegnata personalmente al funzionario addetto, la firma autografa dovrà essere
apposta in sua presenza. Se la dichiarazione viene spedita o consegnata da terzi dovrà essere sottoscritta con
firma autografa dal candidato che dovrà, inoltre, allegare alla stessa fotocopia semplice di un documento di
identità.
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