ISTITUTO DI ISTRUZIONE SUPERIORE STATALE
“QUINTO ORAZIO FLACCO”
VENOSA
----------------------------------------------------------------( school stamp)
School Name
_________________________________________________________________________________
School Address _________________________________________________________________________________
City and Nation_________________________________________________________________________________
Tel. number
__________________________________________________________________________________
Fax number
__________________________________________________________________________________
Certified e-mail address___________________________________________________________________________
E-mail address__________________________________________________________________________________
Participating Teacher’s Personal Data
Surname ___________________________________ Name ______________________________________________
Birthplace
__________________________________________ Date of Birth
M
F
_____________________________
Full address ____________________________________________________________________________________
Cell. Number ___________________________________
E-mail address ______________________________
To the HEADMISTRESS
I.I.S.S. “Quinto Orazio Flacco”
85029 VENOSA (PZ)
We are sending n° _____ entry form/s submitted by the under-mentioned applicant/s who wish/es to participate in the
XXIX CERTAMEN HORATIANUM, taking place in Venosa on 17h April 2015.
APPLICANT’S SURNAME
APPLICANT’S NAME
GENDER
M
F
M
F
I certify that the applying candidates have all the requisites required by the Regulations
Date ________________
THE HEADMASTER
__________________
SEDI:
LICEO CLASSICO- SCIENTIFICO-MUSICALE – Via Emilia, 32 – 85029 Venosa (Pz)
Tel. - Fax 0972 – 31476 (seg.) 0972 – 31332 (pres.)
IPSIA - Via degli Altavilla – 85029 Venosa (Pz)
Tel. - Fax 0972 - 37074 (IPSIA)
[email protected]
[email protected]
www.liceovenosa.gov.it
C.F. 8600219076
C.M. PZIS02100C
TO THE HEADMISTRESS
I.I.S.S. “Quinto Orazio Flacco”
85029 VENOSA (PZ)
XXIX CERTAMEN HORATIANUM - APPLICATION FORM
APPLICANT’S PERSONAL DATA
Surname
Name
______________________________________________________________________________________
Birthplace
Date of birth
Full address
_________________________________________________________________________________
E-mail address _________________________________________________________________________________
Tel. Number
______________________________________________________________________________
Cell. Number
______________________________________________________________________________
I wish to participate in the XXIX Certamen Horatianum which will be held in Venosa on the 17th April 2015.
(tick accordingly):
•
FRENCH
ENGLISH
GERMAN
I will translate the Latin passage into
PORTUGUESE
SPANISH
I will draw/paint using the following technique ______________________________________
I need:
1 drawing sheet
or
1 canvas
I understand and accept the attached 2015 Certamen Horatianum Regulations and Entry Guidelines. I grant permission for my personal information
to be used for this competition, according to Italian Law 196/2003.
----------------------------------------------(Applicant’s Signature)
THE HEADMASTER
Date ....................................
----------------------------------------------
__________________________________________________________________________________________________________________________________________________________________
This document is confidential and may also contain privileged information regarding the above mentioned people, schools and societies. If you are not the intended recipient you are
not authorized to read, print, save, process or disclose this message. If you have received this e-mail by mistake, please delete it, its attachments and any copies attached to it or inform
the sender immediately by sending an e-mail to [email protected] or by calling the number 0039 0972 31476. Any use, distribution, reproduction or disclosure by any person
other than the intended recipient is strictly prohibited and the responsible may incur penalties according to the Italian Law (art. 616 c. p. and D.lgs. n° 196/2003).
SEDI:
LICEO CLASSICO- SCIENTIFICO-MUSICALE – Via Emilia, 32 – 85029 Venosa (Pz)
Tel. - Fax 0972 – 31476 (seg.) 0972 – 31332 (pres.)
IPSIA - Via degli Altavilla – 85029 Venosa (Pz)
Tel. - Fax 0972 - 37074 (IPSIA)
[email protected]
[email protected]
www.liceovenosa.gov.it
C.F. 8600219076
C.M. PZIS02100C