COMPETITION CALL FOR THE ADMISSION TO THE THIRD YEAR OF THE SIX-YEAR
SINGLE-CYCLE DEGREE COURSE IN MEDICINE AND SURGERY OF THE “A. GEMELLI”
FACULTY OF MEDICINE AND SURGERY – ACADEMIC YEAR 2015/2016
Art. 1 – Number of available positions and eligibility requirements for the admission test
A public competition has been opened at the Università Cattolica del Sacro Cuore for the Academic Year
2015-2016, concerning the admission to the third year of the six-year single-cycle Degree Course in Medicine
and Surgery (0H0A), for n. 2 places reserved to Italian and EU citizens living anywhere and to non-EU
citizens legally living in Italy with “permesso di soggiorno” (residence permit)1.
Only those candidates who are currently enrolled (either in due course, as repeating students or not in due
course) in the second year of an English-taught Medicine and Surgery Degree Course may submit an
application to the competition at hand.
In order to be considered eligible to participate to the admission test, candidates are required to satisfy the
following conditions:
-
having passed at least n. 10 exams among the following activities (refer to the Course Plan herein
enclosed in the Annex A) 2:
1
As per the Italian Law no. 286/1998, art. 39 as modified by the Law no. 189/2002, art. 26: “È comunque consentito l’accesso ai corsi
universitari, a parità di condizioni con gli studenti italiani, agli stranieri titolari di carta di soggiorno, ovvero di permesso di soggiorno
per lavoro subordinato o per lavoro autonomo, per motivi familiari, per asilo politico, per lavoro umanitario, o per motivi religiosi,
ovvero agli stranieri regolarmente soggiornanti da almeno un anno in possesso di titolo di studio superiore conseguito in Italia, nonché
agli stranieri, ovunque residenti, che sono titolari dei diplomi finali delle scuole italiane all’estero o delle scuole straniere o
internazionali, funzionanti in Italia o all’estero, oggetto di intese bilaterali o di normative speciali per il riconoscimento dei titoli di
studio e soddisfino le condizioni generali richieste per l’ingresso per studio”.
A liberal English translation of the aforementioned Law is herein provided: “The admission to University programs is allowed at any
rate, on the same conditions as Italian students, to foreigners holding a Resident Card (carta di soggiorno), as well as a residence
permit (permesso di soggiorno) for subordinate or independent work, for family reasons, for political asylum, for humanitarian work, or
for religious reasons; to foreigners legally living in Italy for at least one year and holding a High School qualification achieved in Italy;
to foreigners living anywhere and holding a High School qualification issued by Italian schools located abroad or by foreign or
international schools, operating in Italy or abroad, that abide by bilateral conventions and special terms for the acknowledgement of
High School qualifications, also satisfying the general conditions required for the access for study reasons”.
2
The Course Plan of Medicine and Surgery establishes that, in order to be able to enroll to the third year, students must have passed all
the exams of the previous years within the September exam session, minus two. It is however compulsory to pass the two remaining
exams within the following December session in order to remain in due course. Theology and Language exams represent an exception
to the rule and do not count towards the realization of this condition.
Furthermore, in order to sit for the exams of a certain year, students must have passed all the exams which pertain to the previous year
and this rule applies to every year, from the first up to the sixth.
Page 1 of 18
-

Introduction Course to Medicine

Molecules and Cells

Electromagnetism and Physiology of Excitable Cells

Organic and Functional Systems I

First Aid and Nursing Practice I

Residency and Health Center

Organic and Functional Systems II

Organic and Functional Systems III

Family, Society and Health

First Aid and Nursing Practice II

Informatics

Methodology of Research
having a High School qualification obtained after 12 years of global schooling. Candidates with less
than 12 schooling years are required to submit a certification of their Academic Eligibility (where
applicable) or non-University post-High School studies (with all the exams that have been passed and
any official documentation detailing the contents of the attended Course);
The aforementioned requirements shall be verified by a specific Requirement Evaluation Commission, whose
members are determined by the Board of the Faculty of Medicine and Surgery and include the Coordinating
Professors of each year (first, second and third year), or their delegates.
The Commission will examine the curriculum of each candidate and will declare the names of the candidates
who are admitted to the written test, by means of an official Convocation to the Written Test that will be
published on the website http://www.ucscinternational.it by September 14 2015 (CEST).
Art. 2 – Applying to the admission test
Candidates may submit their application to the test starting from July 1 2015 and no later than August 28
2015 by midnight (CEST). In order to do so, they are required to comply with the following procedure:
1) fill in the form herein enclosed in the Annex B;
2) acquire the following documentation:
Page 2 of 18

a Passport photocopy or, in the case of non-EU candidates legally living in Italy, a photocopy
of the residence permit;

a photocopy of the High-School qualification;

the “Dichiarazione di Valore” (DV / Statement of Validity) for your High-School qualification.
The Dichiarazione di Valore is an official document which provides a short description of a
student’s qualification, its validity in the awarding country to academic and/or professional
ends, as well as the legal status of the awarding Institution. It is issued by the Italian Embassy /
Consulate within the Country of the educational system that awarded the qualification3;

a certification of Academic Eligibility (Idoneità Accademica), if it is required to enroll into an
Academic Program in the country of the High School attended by the candidate;

a transcript of all the exams passed and the corresponding marks achieved by the candidate (in
English);

a certification of attendance to the lectures, in case the attendance was mandatory in the
Academic Program previously attended by the Candidate (in English);

the Curriculum Syllabus of the Academic Program previously attended by the candidate,
illustrating its contents (in English, University Letterhead);

an English Language certification, satisfying the following minimum scores:
o
ACADEMIC IELTS = 6.0;
o
TOEFL IBT = 80;
o
TOEFL Computer Based =213;
o
TOEFL Paper Based = 550;
o
CAMBRIDGE ESOL FCE Grade B
Only those candidates who have attended the entirety of their High School studies in English
may be exempted from submitting the English Language certification. In that case, it is
mandatory for the candidate to submit adequate evidence of the language used in their High
School education in its entirety. The validity of the English Language Certifications will also
be subject to evaluation by the Requirement Evaluation Commission;
3
Further information can be found on the website of the Ministry of Education, University and Research (M.I.U.R.) http://www.miur.it,
in the section pertaining to “Università”, tag “Studenti stranieri”, heading “Norme per l’accesso degli studenti stranieri ai corsi
universitari”.
Page 3 of 18
3) send the Annex B form duly filled in, along with all the required documentation above indicated,
by means of recorded delivery towards:
Ufficio Bandi e Ammissioni / Servizi per Corsi Accademici e Servizi per gli Studenti
Università Cattolica del Sacro Cuore
Largo Francesco Vito, 1 00168 Rome (Italy);
4) forward the same documents digitally, in PDF format, to the following e-mail address:
[email protected];
5) perform the payment of the Application Fee by means of a Bank / Wire Transfer. This fee consists of a
contribution for the public competition expenses, amounting to €160 (one hundred and sixty Euro). The
payment must be made using the following parameters:
Amount
€ 160 (one hundred and sixty Euro)
Account name / Beneficiary
Università Cattolica del Sacro Cuore
Largo Francesco Vito 1
00168, Rome
Italy
Bank name
UniCredit S.p.A. (Agenzia ROMA 60 – Policlinico Gemelli)
Bank address
Largo Agostino Gemelli, 8
00168, Rome
Italy
Bank Identifier Code / Swift Code
UNCRITM 1B41
Bank account number /
IT 70 A 02008 05314 000102942763
IBAN coordinates
Reason of payment / “causale”
MEDICINE AND SURGERY THIRD YEAR 2015-2016 –
APPLICATION FEE
Page 4 of 18
6) Upon performing the payment, send the receipt digitally, in PDF format, by e-mail to
[email protected], no later than August 28 2015 within midnight (CEST). The
payment of the application fee of €160 is not refundable in any circumstance.
Art. 3 – Candidates with disabilities
In accordance with the Italian Law no.104, February 5th 1992 and as modified by the Law n. 17/1999, and
similar laws in the other Countries, candidates with disabilities must submit a certification attesting their
condition and formally request any means of support/help to [email protected], no later than
August 28 2015 by midnight (CEST).
Likewise, in accordance with the Italian Law no. 170/2010, candidates suffering from Learning Disabilities and
Disorders must submit a certification attesting their condition and formally request any means of support/help
to [email protected], no later than August 28 2015 by midnight (CEST).
The provided certification will be subject to evaluation and the candidates may receive up to 30% additional
time to complete the admission test. The Commission reserves the right to conduct the necessary checks on the
certifications provided by the Candidates and shall determine the amount of additional time individually
awarded. Moreover, the Commission reserves the right to evaluate any request of further support/help.
On the day of the test, candidates with Learning Disabilities and Disorders are kindly asked to bring with them
the certification of their condition in its original form.
Art. 4 – Structure and contents of the admission test
Admission to the 6-year single-cycle Degree course in Medicine and Surgery is determined by the results of the
admission test, which consists of both a written and an oral test.
Written test
The written test consists of 100 (one hundred) multiple choice questions, divided as follows:
o
95 questions on psycho-attitudinal subjects (logic, visual space reasoning, text understanding,
attention and precision, numerical reasoning, problem solving);
o
5 questions on religious culture and ethical culture.
Page 5 of 18
Candidates have 100 minutes to complete the written test. The evaluation criteria will be the following:
o
1 point for each correct answer;
o
minus 0.25 points for each wrong answer;
o
no points for no answer.
The minimum score required to pass the written test is 35 (thirty five) points out of 100 (one hundred). Only
those candidates who achieve at least 35 points out of 100 in the written test will be admitted to sit for the oral
test.
Oral test
The oral test consists of an individual interview focused on motivational aspects, as well as elements of general
culture and ethical / religious culture. The interview aims to verify the candidates’ competency and disposition
with regard to their choice of studying at the Università Cattolica del Sacro Cuore.
The oral test will be held in English by an Oral Test Commission, whose members are determined by the Board
of the Faculty of Medicine and Surgery and shall be made up of three Professors (of which one is a Full
Professor) and one Pastoral Assistant.
At the end of the interview, each member of the Commission will award their score to the candidate, ranging
from 0 to 25 points (for a maximum of 100 points).
In case that the admitted candidates to the oral test are equal or less in number than the 2 places available for
this competition, the oral test will not take place. Should that occur, the admitted candidates may immediately
proceed with the Enrollment to the Course, as per the terms established in Art. 7 of this Competition Call.
Final score
The final score of each candidate (for a maximum of 200 points) is calculated by adding the score obtained in
the written exam (for a maximum of 100 points) to the score obtained in the oral exam (for a maximum of 100
points). In case of a tie, the following criteria will be applied in order to determine the prevailing candidate:

the score obtained in the written exam;

the score obtained in the oral exam;

in case of a further tie, the youngest candidate will prevail.
Page 6 of 18
Art. 5 – Dates and venues of the admission test
The written test will take place on September 17 2015 (CEST), by the premises of the Università Cattolica del
Sacro Cuore – Rome Campus (Sede di Roma), located in Largo Francesco Vito 1, 00168 Rome (Italy).
Candidates will be invited to come by the Faculty that day at 10.00 am (CEST)
The specific test hall location will be notified within the official Convocation to the Written Test, that will be
published both on the official Faculty billboards and on the website http://www.ucscinternational.it by
September 14 2015 (CEST).
The results of the written test and the official Convocation to the Oral Test will be published both on the
official Faculty billboards and on the website http://www.ucscinternational.it by September 22 2015 (CEST).
The oral test will take place on September 24 2015 (CEST), by the premises of the Università Cattolica del
Sacro Cuore – Rome Campus (sede di Roma).
The University reserves the right to modify the date and venue arrangements of the test at any time, should this
be required for organizational reasons. In the event that such a change occurs, candidates will be promptly
informed by an official notice published on http://www.ucscinternational.it.
On the days of the admission test, both for the written and the oral test, candidates will have to provide the
Commission with a valid ID document among the following:
o
ID Card;
o
Driving license;
o
in the case of non-Italian EU students, a valid passport;
o
in the case of non-EU students legally living in Italy, a valid residence permit.
Moreover, candidates will be required to show the payment receipt of the Application Fee to the Commission,
as well as any original document attesting possible Disabilities or specific Disorders, as per Art. 3 of the
present document.
It is absolutely forbidden for any candidate to use mobile phones, tablets, laptops, calculators, books, notes, or
any web-connecting device during the test. Furthermore, candidates who arrive after the initial ID operations
have been performed will not be allowed to sit for the test.
Page 7 of 18
Art. 6 – Results of the admission test
The final ranking will be published both on the official billboards of the Faculty of Medicine and Surgery “A.
Gemelli” and on the website http://www.ucscinternational.it starting from September 29 2015 (CEST).
The candidates who achieve the first useful positions of the final ranking will be declared as the winners of the
competition and may proceed with the Enrollment to the Course, as per the terms established in Art. 7 of this
Competition Call.
Art. 7 – Enrollment
The winner candidates of the competition may enroll in the Medicine and Surgery Degree Course no later than
October 9 2015 (CEST), by completing the following procedure:
1) perform the payment of the Enrollment Fee, consisting of the first University fee installment and
amounting to € 4.000 (four thousand Euro). The payment of the Enrollment Fee of € 4.000 must
be done by means of a Bank / Wire Transfer with the following parameters and is not refundable in
any circumstance:
Amount
€ 4.000 (four thousand Euro)
Account name / Beneficiary
Università Cattolica del Sacro Cuore
Largo Francesco Vito 1
00168, Rome
Italy
Bank name
UniCredit S.p.A. (Agenzia ROMA 60 – Policlinico Gemelli)
Bank address
Largo Agostino Gemelli, 8
00168, Rome
Italy
Bank Identifier Code / Swift Code
UNCRITM 1B41
Page 8 of 18
Bank account number / IBAN
IT 70 A 02008 05314 000102942763
coordinates
Reason of payment / “causale”
MEDICINE AND SURGERY THIRD YEAR 2015-2016 –
ENROLLMENT FEE
2) send a copy of the payment receipt of the first University fee instalment attached by email to
[email protected] no later than October 9 2015 (CEST);
3) deliver the following documentation in its original form to the front-office of the “Polo Servizio
Carriera Studenti” of the Università Cattolica del Sacro Cuore – Rome Campus (Sede di Roma),
located in Largo Francesco Vito 1, 00168 Rome (Italy) no later than October 9 2015 (CEST):

Statement of Acceptance (provided to the winners of the competition in PDF format by
e-mail);

Request addressed to the Rector (provided to the winners of the competition in PDF
format by e-mail);

“Statement of Acceptance” of the Ethics Code (provided to the winners of the
competition in PDF format by e-mail);

all the documentation listed under Art. 2 of the present Competition Call (in its
original form);

two passport-size photos (with the candidate’s name and surname written on the back
side);

the official Transfer Request statement issued by the University previously attended by
the candidate;

a photocopy of ID document / Passport and Codice Fiscale (tax / fiscal code). The
Codice Fiscale is an official Italian document, consisting of a 16-character
alphanumeric code issued free of charge to identify both Italian nationals and foreign
residents and allow any financial operations.

Christening certificate (only for Catholics). In the absence of the certificate, candidates
will arrange an appointment with a Pastoral Assistant (at any time, even after the
Enrollment);

Photocopy of a valid residence permit (only for non-EU candidates legally living in
Italy);
Page 9 of 18
4) submit the following documentation in its original form to the Servizio di Sorveglianza Sanitaria Università (Sanitary Surveillance Service – University), located on Floor II of the Biological
Institutes (Istituti Biologici) of the Università Cattolica del Sacro Cuore – Rome Campus (Sede di
Roma), in Largo Francesco Vito 1, 00168 Rome (Italy):

Certificate of vaccination for hepatitis B;

Certificate of anti-tuberculin Mantoux test, performed no more than 3 months before,
as established in the Guidelines for the Control of the Tuberculin Disease
(provvedimento n. 17712/1998 della Conferenza Stato-Regioni).
Upon submission of the aforementioned certificates, the Sanitary Surveillance will issue a receipt,
that the student is required to hand over to the front-office of the “Polo Servizio Carriera Studenti”
of the Università Cattolica del Sacro Cuore – Rome Campus (Sede di Roma), located in Largo
Francesco Vito 1, 00168 Rome (Italy) no later than October 27 2015 (CEST)
Those candidates who have won the Competition and proceed with the enrollment in the third year
of the Medicine and Surgery Degree Course will also have to sit for a medical examination
performed by the Sanitary Surveillance. This exam aims to verify the eligibility of the candidates’
psycho-physical status for the clinical functions required by the Course. In case that the results of
this examination are negative, the candidate may be prevented from completing the Enrollment to
the Course.
Front-office opening hours:
Monday
9.30 am – 3.00 pm
Tuesday
9.30 am – 3.00 pm
Wednesday
9.30 am – 3.00 pm
Thursday
1.00 pm – 4.00 pm
Friday
9.30 am – 12.00 pm
Page 10 of 18
General Deadlines
Publication of the Competition Call
July 1 2015 (CEST)
Application and application fee payment deadline
August 28 2015 (CEST)
Convocation to the Written Test
By September 14 2015 (CEST)
Written Test
September 17 2015 (CEST)
Results of the Written Test and Convocation to the Oral Test
By September 22 2015 (CEST)
Oral Test
September 24 2015 (CEST)
Results of the Admission Test and publication of the Ranking
Starting from September 29 2015 (CEST)
Enrollment deadline
October 9 2015 (CEST)
Delivery of medical certifications to the Sanitary Surveillance
October 27 2015 (CET)
and delivery of the Sanitary Surveillance receipt to the FrontOffice of the “Polo Servizio Carriera Studenti”
Candidates that do not comply with the provisions indicated in the present Competition Call by the
corresponding deadlines shall be considered as 'withdrawn'; vacant places shall be made available to other
candidates according to the merit ranking.
PLEASE NOTE
• The University reserves the right to conduct all the necessary checks prescribed by the Law on the
declarations and documents provided by the candidates. Should these declarations be false, the University
may apply disciplinary measures established by current Law, up to the potential expulsion of the student.
• Fees and contributions are determined by the Governing Bodies of the Università Cattolica del Sacro Cuore.
For further information refer to the following website (in Italian): http://roma.unicatt.it.
• The Administrative Manager in charge of the procedure is Dr. Francesca Mencarelli (Mrs.), Responsible of
Page 11 of 18
the Academic Programs and Student Services of the Università Cattolica del Sacro Cuore - Rome Campus.
• The present Competition Call is established in accordance with the Italian Law. The competent “Foro”
(Court) in charge is the one of Rome.
For any further inquiries, candidates may:

send an e-mail message to [email protected];

call the following telephone number: (+39) 06 30158705
o
from Monday to Thursday from 10.00 am to 4 pm
o
on Friday from 10.00 am to 2 pm.
Rome, July 1 2015
The Administration Director
Rector
Prof. Marco Elefanti
Prof. Franco Anelli
Page 12 of 18
ANNEX 'A'
COURSE PLAN OF THE FIRST YEAR AND SECOND YEAR OF THE
6-YEAR SINGLE- CYCLE DEGREE COURSE IN MEDICINE AND SURGERY
FACULTY OF MEDICINE AND SURGERY “A. GEMELLI” – ACADEMIC YEAR 2015/2016
First year [D.M. 270/2004]
MH1101 Introduction Course to Medicine
MH1159 Medical and Health Psychology I: Foundations
M-PSI/08
MH1158
Biology
BIO/13
MH1157
Clinical Symptomatology
MED/09
MH1156
Clinical Anatomy
BIO/16
MH1155
Chemistry/Biochemistry
BIO/10
MH1154
Biostatistics
MED/01
MH1153
Informatics
INF/01
MH1152 Ethical principles for undergraduate students
MED/43
MH1151 Description of students evaluation and examination
methods
BIO/17
MH1161
BIO/10
Laboratory (Safety and Health)
MH1150 Description of the overall course organization
MED/09
MH1160
FIS/07
Physics I: Introduction
MH1102 Molecules and Cells
MH1169
Electric and electronic measures
ING-INF/07
MH1168
Physics II: Mechanics
FIS/07
MH1167
General Microbiology
MED/07
MH1166
Histology and General Embryology
BIO/17
MH1165
Molecular Biology
BIO/11
MH1164
Genetics
MED/03
MH1163
Cellular Biology
BIO/13
MH1162
Chemistry/Biochemistry
BIO/10
MH1170 Physics III: Thermal Physics and Waves
FIS/07
MH1203 Electromagnetism and Physiology of Excitable Cells
MH1272
Cell Physiology
BIO/09
Page 13 of 18
MH1271
Physics IV: Electromagnetism
FIS/07
MH1204 Organic and Functional Systems I
MH1279
Heart: Anatomy
BIO/16
MH1278
Heart: Embryology
BIO/17
MH1277
Skeletal-muscle System: Physiology
BIO/09
MH1276
Skeletal-muscle System: Biochemistry
BIO/10
MH1275
Skeletal-muscle System: Histology
BIO/17
MH1274
Skeletal-muscle System: Anatomy
BIO/16
MH1273
Skeletal-muscle System: Embryology
BIO/17
MH1282
Heart: Physiology
BIO/09
MH1281
Heart: Biochemistry
BIO/10
MH1280
Heart: Histology
BIO/17
MH1205 First Aid and Nursing Practice I
MH1284
Nursing Practice I
MED/45
MH1283
First Aid I
MED/41
MH1206 Residency in Health Center
MH1285 Risk Management, Safety and Health
MED/42
Second Year [D.M. 270/2004]
MH2101 Organic and Functional Systems II
MH2159
Vascular System: Embryology
BIO/17
MH2169
Digestive System: Histology
BIO/17
MH2168
Digestive System: Anatomy
BIO/16
MH2178
Endocrine System: Physiology
BIO/09
MH2167
Digestive System: Embryology
BIO/17
MH2177
Endocrine System: Histology
BIO/17
MH2166
Respiratory system: Physiology
BIO/09
MH2176
Endocrine System: Anatomy
BIO/16
MH2165
Respiratory System: Histology
BIO/17
MH2175
Endocrine System: Embryology
BIO/17
MH2164
Respiratory System: Anatomy
BIO/16
MH2174
Urinary System: Physiology
BIO/09
Page 14 of 18
MH2163
Respiratory System: Embryology
BIO/17
MH2173
Urinary System: Histology
BIO/17
MH2162
Vascular System: Physiology
BIO/09
MH2172
Urinary System: Anatomy
BIO/16
MH2161
Vascular System: Histology
BIO/17
MH2171
Urinary System: Embryology
BIO/17
MH2160
Vascular System: Anatomy
BIO/16
MH2170
Digestive System: Physiology
BIO/09
MH2201 Organic and Functional Systems III
MH2279
Reproductive System: Embryology
BIO/17
MH2187
Nervous System General Psychology
M-PSI/01
MH2286
Nervous System: Physiology
BIO/09
MH2285
Nervous System: Histology
BIO/17
MH2284
Nervous System: Anatomy
BIO/16
MH2283
Nervous System: Embryology
BIO/17
MH2282
Reproductive System: Physiology
BIO/09
MH2281
Reproductive System: Histology
BIO/17
MH2280
Reproductive System: Anatomy
BIO/16
MH2204 Family, Society and Health
MH2289
History of Medicine
MED/02
MH2288
Anthropology
BIO/08
MH2290
Bioethics and Medical Humanities
MED/43
MH2205 First Aid and Nursing Practice II
MH2292
Nursing Practice II
MED/45
MH2291
First Aid
MED/41
MH2207 Informatics
MH2293
Informatics
INF/01
MH2209 Methodology of Research
MH2294
Methodology of Research
MED/42
Page 15 of 18
ANNEX 'B'
APPLICATION FORM FOR THE ADMISSION TO THE THIRD YEAR OF THE
6-YEAR SINGLE- CYCLE DEGREE COURSE IN MEDICINE AND SURGERY
FACULTY OF MEDICINE AND SURGERY “A. GEMELLI”– ACADEMIC YEAR 2015 / 2016
-
to be sent by Recorded Delivery no later than August 28 2015 (CEST) to:
Ufficio Bandi e Ammissioni / Servizi per Corsi Accademici e Servizi per gli Studenti
Università Cattolica del Sacro Cuore
Largo Francesco Vito, 1 00168 Rome
Italy
-
to be forwarded in PDF format no later than August 28 2015 (CEST) to:
[email protected]
Academic Programs and Students Services
Università Cattolica del Sacro Cuore
University:
Università Cattolica del Sacro Cuore - Rome Campus
Faculty:
Medicine and Surgery “A. Gemelli”
Program Name:
Medicine and Surgery (English-taught)
Duration of the Program:
6 years
Admission test dates:
September 17 2015 (written test)
September 24 2015 (oral test)
Page 16 of 18
Personal Data (as written on the passport)
Last Name
First Name
Middle Name
Gender
Date of Birth
Place of Birth
Country of Birth
Nationality /
Citizenship
Residence
Address
City
State
Country
Postal Code
Page 17 of 18
Contact Information
Telephone
number
Mobile phone
number
E-mail address
Date ________________________
Signature ________________________________________
Page 18 of 18