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*Name:
*Surname:
*Birth date:	--
*Telephone:
*E-mail:
*Region:
*Province:
*Profession:
Are you registered with an Employment Centre?:
if yes, since when?:
Invalidity:
if yes, %:
Do you have a car?:
*Allega curriculum:
Privacy clause:	NOTICE (pursuant to section 13 of Legislative Decree no. 196 dated 30.06.03) I hereby declare that I am aware that all personal and sensitive information I may provide will be used to send me the requested information on healthcare and/or assistance services and of the fact that this information may be communicated to third parties involved in providing the service. Finally, I acknowledge that the data supervisor is the head of the office to which the data in question is sent. I am aware that I may exercise my rights under section 7 of the above-mentioned Legislative Decree 196/2003 on the premises of Mai Soli.
I accept:


	*mandatory fileds

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