1. Healthcare

Club di Cremona
A scholarship to attend CEEP courses in Cremona (Italy)
Application Form
Identity record
Name: …………………………………………………………………………………………………………………………………………...
Surname: ……………………………………………………………………………………………………………………………………….
Birth date: ……………………………………………………………………………………………………………………………………..
Nationality: ……………………………………………………
Gender:
□ M□ F
Passport/Identity card N°: …………………………………………………………………………………………………………….
Address: …………………………………………………………………………………………………………………………………..……
City: ……………………………….……..
State: …………………………………….
Zip code: ……………………………….
Telephone: ……………………………………………………. E-mail address: …………………………………………………
Educational background
College/Universityname: ……………………………………………………………………………………………………………...
Location (city/State): …………………………………………………………………………………………………………………….
Date of attendance from: ………………………………………………………………………………………………….…………..
Date of attendance to: …………………………………………………………………………………………..………………………
Certificate degreeawarded: ……………………………………………………..……………………………………………..……
SDS (ScientificDisciplinary Sector): ...................................................................................................
Club di Cremona
Job position
Currentemployer: ……………………………………………………………………………………………..………………………...
Location (city/State): …………………………………………………………………………………………………………………….
Current job/position: ……………………………………………………………………………………………………….…………..
Date of attendance from: ……………………………………………………………………………………..………………………
Preferred CEEP course
|_||_||_||_||_| ………………………………………………………………………………………………….
(5 digit-code)(title)
Whether you have a 2nd-best or a 3rd-best choice of CEEP course, please type the code and its title
in the below-given spaces:
|_||_||_||_||_| ………………………………………………………………………………………………….
2° choice:
(5 digit-code)(title)
3° choice:
|_||_||_||_||_| ………………………………………………………………………………………………….
(5 digit-code)(title)
Applicant’s signature Date
Please enclose:
o Curriculum vitae (CV) of the applicant, which should include past education and professional
experience, and current employment status;
o Cover letter, clearly stating the reason why they want to take part in the training;
• Two letters of recommendation as a reference. The first one should be written by a
university professor who has known the candidate. The second one should be written by the
current or a former employer. If the applicant has never worked outside the university, the
two letters of recommendation must be completed by two different professors. A third letter
of recommendation written by a national public official, by a government official or other
person working for a semi -governmental organization or agency will be considered a
preferential requirement.
For more information: [email protected]