14th INTERNATIONAL EDITION OF PREMIO VIRTUOSITE’

14th INTERNATIONAL EDITION OF “ PREMIO VIRTUOSITE’ ”

Scheda di iscrizione - Application form - Demande d'inscription – Einschreibungsautag

THE APPLICATION FORM IS NOT ACCEPTABLE WITHOUT THE RECEIPT OF
PAYMENT AND THE FORM ATTACHED

REQUEST PIANIST ACCOMPANIST YES NO (please tick)

If you request the pianist accompanist, please send as soon as possible the name of the music
score selected by mail to [email protected]

Instrument...............................................................

Surname .................................................................................................................
Name......................................................................................................................... ....

Nationality .........................................................................................................
Place of Birth...................................………………………………………

Date of Birth..................................................................................................
Address Street.................................................................................. n°............…………………..

Zip Code..........................................................................................................................

Town......................................................................................................................... ......

Country....................................................................................................................................
e-mail OBLIGATORY (clearly legible) …………………………………………………..
mobil phone number OBLIGATORY (clearly legible) …………………………………...
Phone................................................................…………………………………………

Composer............................................. .............................................................
Piece...................................................... .............................................................
Minutes.................................................. .............................................................

Composer............................................. .............................................................
Piece...................................................... .............................................................
Minutes.................................................. .............................................................

Composer............................................. .............................................................
Piece...................................................... .............................................................
Minutes.................................................. .............................................................

Composer............................................. .............................................................
Piece...................................................... .............................................................
Minutes.................................................. .............................................................

Teacher (not obligatory) .............................................................

Entry Fee € 80

Surtax for pianist accompanist (if required)
€ 35 YES NO (please tick)
(please one only payment)

I enclose:
- A personal identity certificate
- Photocopy of application entry fee bank transfer receipt, otherwise the application form
will not be accepted
- Biography (curriculum)
- COMPILATION OF THE FORM ATTACHED (OBLIGATORY). For the minors, it is
necessary the compilation by one parent (requested the only data of one parent).

I declare that I agree and accept unconditionally all the provisions of the Competition Rules
and any changes made by the Art Director. I agree to the publicate name on the AGIMUS
website if it is among the winners of the competition. I accept without objection of any kind
the results of the jury.

Date ......................................................................

Signature............................................

Signature of parent for minors.......................................................

DEMAND OF REGISTRATION AS ORDINARY MEMBER OF PADOVA AGIMUS ASSOCIATION

NAME ______________________________ SURNAME ____________________________________________

Place of birth ____________________________ province ____________ date _________________________

Residence _____________________ address _______________________ n. __________ postal code _____________

Tel. __________________________ Mobile _______________________ e-mail _____________________________

ordinary member

By signing, you authorize AGIMUS to process your data for records and for the management of the aforementioned
information, in accordance with Law no. 675 of 31.12.1996. This request is not entitled to vote at the meeting, because
the claim must be approved by the National Executive Committee (see Internal Regulations). Only after the approval
and ratification of the National Executive, the applicant acquires the status of a member with all the consequent rights
and responsibilities.
PROPONENT MEMBER (surname and name) ________________________________________________________

Acceptance signature ________________________________________ Date ________________________________

Amount paied € 15

Dear Mr. ……………………………………………………………….

Following the demand of registration for the section AGIMUS Padova and finalized the entry in the register of members
of the Association. Hereby, pursuant to art. 13 D. Decree 196/2003 (Code for the protection of personal data) provides
the following information:

• The data will be used for the implementation and the purposes of the assignment indicated. The same treatment will
be carried out in compliance with the aforementioned law and the obligations of confidentiality contained therein and
shall follow principles of correctness, lawfulness, transparency and protection of privacy and rights of the individual;
• Some of these personal data might fall into the category of sensitive data pursuant to art. 26 of Legislative Decree
196/2003, as it can reveal the racial and ethnic origin, religious, philosophical or other beliefs, political opinions,
membership of parties, trade unions, associations or organizations of a religious, philosophical, political or trade union
membership, health status and sex life; treatment, intended for the performance of the assignment, relates only to the
data necessary for the performance of the Competition assignment;
• The data will be processed manually and / or in an automated way according to the needs that arise;
• the transfer of data is required and without the consent referred to STEP 1 and STEP 2 will not be able to initiate the
engagement;
• Personal data may be disclosed to any other person responsible to conduct, even in part, to activities related to the
assignment;
• in relation to the processing of personal data, you can exercise, even by proxy or power of attorney to an individual
or association, the rights under Art. 7 D. Decree 196/2003, of which the person claims to be aware of;
• the holder of AGIMUS data is the legally represented by RAFFAELE BEVILACQUA domiciled in Rome via F. Di
Cambiano, 26 and responsible for processing the data for the purpose of exercising the rights of the person referred
to in D. Decree 196/2003 is Mr. RAFFAELE BEVILACQUA.
Declaration of Consent
The undersigned ________________________________________________________________________________
Born in ___________________________________On __________________________________________________
Resident in __________________________________________ postal code _______________________________
Address __________________________________________________________ n. ___________________________
in regards to the above, received pursuant to art. 13 D. Decree 196/2003 and subsequent amendments:
STEP 1 - gives its Consent, pursuant to art. 23 of Legislative Decree 196/2003, the processing of his personal data,
including sensitive data such purpose therein, in the manner described above
Signature ______________________________________________________________________________________
STEP 2 - gives his CONSENT to the disclosure of personal data, for the proper purpose of the assignment, to other
persons competent to carry out the mandate.
Signature ___________________________________________________________________________________
Date ____________________________________________________________________________________

PRE-FILLED SAMPLE (PLEASE FOLLOW THE INSTRUCTIONS BELOW)

DEMAND OF REGISTRATION AS ORDINARY MEMBER OF PADOVA AGIMUS ASSOCIATION

NAME Mario SURNAME Rossi

Place of birth Padova province (PD) date 30/12/1980

Residence Padova address Via Gattamelata n. 18 postal code 35120

Tel. 049 1234567 Mobile 3381234567 e-mail [email protected]

ordinary member

By signing, you authorize AGIMUS to process your data for records and for the management of the aforementioned

information, in accordance with Law no. 675 of 31.12.1996. This request is not entitled to vote at the meeting, because

the claim must be approved by the National Executive Committee (see Internal Regulations). Only after the approval

and ratification of the National Executive, the applicant acquires the status of a member with all the consequent rights

and responsibilities.

PROPONENT MEMBER (surname and name) Rossi Mario

Acceptance signature Mario Rossi Date 10/04/2014

Amount paied € 15 (nothing has to be paid in add of application form)

Dear Mr. Mario Rossi

Following the demand of registration for the section AGIMUS Padova and finalized the entry in the register of

members of the Association. Hereby, pursuant to art. 13 D. Decree 196/2003 (Code for the protection of personal data)

provides the following information:
• The data will be used for the implementation and the purposes of the assignment indicated. The same treatment will

be carried out in compliance with the aforementioned law and the obligations of confidentiality contained therein and

shall follow principles of correctness, lawfulness, transparency and protection of privacy and rights of the individual;
• Some of these personal data might fall into the category of sensitive data pursuant to art. 26 of Legislative Decree

196/2003, as it can reveal the racial and ethnic origin, religious, philosophical or other beliefs, political opinions,

membership of parties, trade unions, associations or organizations of a religious, philosophical, political or trade union

membership, health status and sex life; treatment, intended for the performance of the assignment, relates only to the

data necessary for the performance of the Competition assignment;
• The data will be processed manually and / or in an automated way according to the needs that arise;
• the transfer of data is required and without the consent referred to STEP 1 and STEP 2 will not be able to initiate the

engagement;
• Personal data may be disclosed to any other person responsible to conduct, even in part, to activities related to the

assignment;
• in relation to the processing of personal data, you can exercise, even by proxy or power of attorney to an individual

or association, the rights under Art. 7 D. Decree 196/2003, of which the person claims to be aware of;
• the holder of AGIMUS data is the legally represented by RAFFAELE BEVILACQUA domiciled in Rome via F. Di

Cambiano 26 and responsible for processing the data for the purpose of exercising the rights of the person referred to

in D. Decree 196/2003 is Mr. RAFFAELE BEVILACQUA.

Declaration of Consent

The undersigned Mario Rossi

Born in Padova On 30/12/1980

Resident in Padova postal code 35120

Address Via Gattamelata n. 18

in regards to the above, received pursuant to art. 13 D. Decree 196/2003 and subsequent amendments:
STEP 1 - gives its Consent, pursuant to art. 23 of Legislative Decree 196/2003, the processing of his personal data,

including sensitive data such purpose therein, in the manner described above

Signature Mario Rossi

STEP 2 - gives his CONSENT to the disclosure of personal data, for the proper purpose of the assignment, to other

persons competent to carry out the mandate.

Signature Mario Rossi

Date 10/04/2014