Ask for Italian Courses -Adult and Major (18+)

Ministero dell’Istruzione, dell’ Università e della Ricerca

Centro Provinciale per l’Istruzione degli Adulti

TRIESTE

MODULO C

ASK FOR ITALIAN COURSES -ADULT AND MAJOR (18+)

To theHead Teacher of CPIA 1 - Trieste

I, (FIRST NAME) ______(NAME)______ M  F

FISCAL CODE ______AGE (completedyears)______

(please, writeclearly, in blockletters)

ASK TO BE ENROLLED for the s.y. 2017/2018

to a coursefinalizedto reach a level of knowing of ITALIAN LANGUAGE atleast of level A2 of Common European Framework of Reference for Languages (CEFR)

BASE COMMUNICATION FOR ILLITERATES  PRE A1

Time slot
(choosepreferenceorder
or "indifferent")
MORNING
AFTERNOON
EVENING
 INDIFFERENT

LEVEL:  A1: BEGINNER  A2: ELEMENTARY  B1: INTERMEDIATE

 B2: UPPER INTERMEDIATE  C1: ADVANCED  C2: PROFICENT

Time slot preference
is due to work?
NO
YES

I DECLARE

To be born in (city) ______Nation ______

on(date)______to be citizen (Nationality)______

To be resident in ______street/square______n.______

(Eventualdomicile ______street/square______n._____)

tel. mobile______othertel.______

mail______@______alreadyattendedcourselevel ______a.s.______

I ASK, for the Individual Training PactRecognition of credits, according to the rules of the administrativeactivity, aware of the responsibilities to whichitappliesif the declarationisnottrue, the recognition of credits, by reserving to attachanyfutherrelevantdocumentation. I enclose the followingdocuments:

______

Self-certificationsignature ______

(Laws 15/1968, 127/1997, 131/1998, dpr 445/2000)

The undersigned, havingtakennotice of the information made by the schoolaccording to art. 13 of DL.vo No.196 / 2003, declaresthat he / sheisawarethat the schoolmay use the data contained in this self-certificationexclusivelywithin the scope and for the institutionalpurposes of the Public Administration (The data released are used by CPIA in compliance with the privacy policy: Legislative Decree 30 june 2003 n.196 and RegulationMinisterialDecree 7 December 2006 n.305).

Trieste, ______Signature ______

QUALIFICATIONS HELD

 PRIMARY SCHOOL(-10)
 in Italy
abroad ______
n. years ______/  FIRST DEGREE SECONDARY SCHOOL (11-13)
 in Italy
abroad ______
n. years ______/  BIENNIO SUPERIOR SCHOOL (14-15)
 in Italy
abroad ______/  PROFESSIONAL QUALIFICATION DIPLOMA
(14-16+)
 in Italy
abroad ______
n. years ______/  SECOND DEGREE SECONDARY SCHOOL (16+)
 in Italy
abroad ______
n. years ______
 UNIVERSITY DEGREE (19+)
 in Italy
abroad ______
n. years ______/  OTHER (19+)
 in Italy
abroad ______
n. years ______/ Total schoolyearsdone:
WORKING CONDITION
 EMPLOYED /  UNEMPLOYED (looking for job, enrolled in placement office) /  NOT EMPLOYED (notlooking for job) /  HOUSEWIFE /  RETIRED
In Italy* from ______
in possession of a regular residence permit Kind of document: ______
awaiting the issuance of the residence permit
First language ______
Second language ______
Knowledge of the Italianlanguage______* Framework to be filledonlyif non-Italiancitizens

Attached:

1)Photocopy of identitydocument

2)Photocopy of valid residence permit or certificate of new request(onlycitizensnotbelonging to the EU)

3)Copy of the payment of € 5,00 to partially cover the costs of the materialprovided (didacticmaterial, photocopies and/or books), asrequired by the regulation, to be done with the homebanking service or at the Bank Office in Piazza della Borsa, 11 to:

Banca Monte dei Paschi di Siena: ENTE 23 - IBAN: IT 08 J01030 02230 000003983655

account holder: CENTRO PROVINCIALE ISTRUZIONE ADULTIDI TRIESTE

cause: quota contributo iscrizione corso di italiano a.s. 2017/2018

Trieste, ______Signature ______

RESERVED TO OFFICE:

La presente domanda è stata registrata in data______n. ______

Inserito nella classe ______in data ______

(spostato nella classe ______in data ______)