Attachment “A”

DICHIARAZIONE SOSTITUTIVA DI CERTIFICAZIONE

AI SENSI DELL’ART. 1, D.P.R. 403/1998

DICHIARAZIONE SOSTITUTIVA DELL’ATTO DI NOTORIETÀ

AI SENSI DELL’ART. 2 E 5, D.P.R. 403/1998

Il sottoscritto_____________________________codice fiscale_________________________nato a______________________________prov._________il___________________sesso____________

residente in via______________________C.A.P.___________cittą __________________________ prov. ____________ telefono___________________________

consapevole delle sanzioni penali richiamate dall’art. 26 della legge 4 gennaio 1968, n. 15 per le ipotesi di falsitą in atti e dichiarazioni mendaci

dichiara

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Data_______________

                                                                                           Firma

                                                                   ____________________________________

Allega fotocopia documento di riconoscimento