Transcript Modulo iscrizione Summer School - Università degli Studi di Foggia

INTERNATIONAL SUMMER SCHOOL A.A. 2014/2015
MUSCULOSKELETAL RADIOLOGY
PARTICIPANT’S PERSONAL DATA
FAMILY NAME:…………………………………………………FIRST NAME:……………………………………………………………………
DATE OF BIRTH:………………………………………………E-MAIL ADDRESS:………………………………………………………….
NATIONALITY:…………………………………………………………………………………………………………………………………………...
TYPE OF STUDENT (MEDICAL STUDENTS, SPECIALIZATION STUDENTS IN RADIOLOGY, RX
TECHNICIAN):…………………………………………………………………………………...................................................................
SENDING INSTITUTION (IF DIFFERENT FROM UNIVERSITY OF FOGGIA):
………………………………………….................................................................................................................................
DATE:
SIGNATURE
N.B. To be filled in in capital letters
To be addressed to “International Relations Department”: [email protected]. Università di Foggia, via Gramsci, 89/91
– 71122 Foggia, administrative contact: Dott.ssa Laura Formato,
Director and Coordinator: prof. Giuseppe Guglielmi, [email protected];
Required documents: application form, receipt of payment, passport photo, identity document (passport or identity
card).