ATTACHMENT 1

Application form for admission to the restricted access Master Degree Programme in 
“Cognitive neuroscience”

First part

The undersigned, in accordance with D.P.R. 28 December 2000, No. 445, hereby declares:

Surname		Name		
Student registration number (it is the number issued by the Infostud System at the end of the registration process)		
Date of birth		Place of birth		Province/County		
Tax identification number:			
Address: Street		No.		
City		
Postal Code		Province/County			
Landline number		Mobile phone		Fax		
E-mail			

Second part

The undersigned also declares that he/she holds the qualifications below: 
(mark with an X the appropriate option and fill in all the required blanks); 

(   ) A. I have earned a Bachelor degree in Psychology (L-24):

Faculty of the degree	
	
Name of the bachelor degree programme		
Academic year of first enrolment in the Bachelor degree programme		
Academic year of graduation		Graduation date		
Final grade		

(   ) B. I am going to earn the bachelor degree within 15 September:

Name of the bachelor degree programme		
Academic year of your first enrolment in the bachelor degree programme 		

(   ) C. I have earned a Second Level 5-year Degree (Old University System regulation):

University of the Second Level Degree (Old University System)		
Faculty of the Second Level Degree (Old University System)		
Name of the Second Level Degree (Old University System)		
Graduation date	
	
Final grade	

(   ) D. I have earned a foreign educational qualification
University of the Degree 		
Faculty of the Degree		
Name of the Degree		
Graduation date		
Final grade		

Third part
The undersigned hereby declares that he/she has taken the exams below:
For students referred to in points A and B of the second part:

Academic Discipline
(SSD)	Name of the learning module	Credits achieved
(ECTS/CFU)	Grade	

				

				

				

				

				

				

				

				

For students referred to in point C of the second part

Specify, for each exam taken at the University you are coming from, if it is a six-month (S) or an annual (A) exam, and also write down, if available, the corresponding Academic Discipline (SSD). 

Academic Discipline	Name of the exam	Six-month or Annual	Grade	

				

				

				

				

				

				

				

				

				

For students referred to in point D of the second part
Students holding a foreign qualification should, when possible, enclose a copy of the documents issued by the University they come from also including the detailed programme of each exam.

Subjects	In class hours	Credits achieved (ECTS/CFU)	Date of the exam	Grade of the exam	

					

					

					

					

					

					

Fourth part

With regard to English language knowledge, the undersigned also declares that:
(mark with an X the appropriate option) 

(   )  he/she is a native English speaker;

(  ) he/she has an adequate B2 English language certificate (ESOL, IELTS o TOEFL) recognised and issued by an authorised institution and enclosed with the present application form;
(   ) he/she does not hold an adequate English language certificate, but has a suitable English language knowledge that will have to be assessed with an interview;

(   ) he/she holds a Bachelor Degree in English.

Fifth part

The candidate, aware of the penalties indicated in Article 76 of the D.P.R. 28/12/2000 No. 445 in the case of false statements, and of the loss of any benefits achieved with the comparative assessment procedure based on untruthful statements referred to in Article 75 of the D.P.R., assumes, in accordance with Article 47 of the above mentioned D.P.R., liability for what is stated in the present application.
By virtue of Article 13 of the EU Regulation No. 679/2016 of 27.04.2016 “General Data Protection Regulation,” the data processing controller is Sapienza University of Rome; the legal representative of the University is the Rector pro tempore. 
Contact details: urp@uniroma1.it; PEC: protocollosapienza@cert.uniroma1.it. 
Contact details of the data protection Officer rpd@uniroma1.it; PEC: rpd@cert.uniroma1.it. 
We hereby inform that the processing of the data collected with the applications for the competition is exclusively run for the purposes related to the procedure for the comparative assessment and for any related enrolment process to manage students’ educational plan.

Rome ____________________

Signature ___________________________________________