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The undersigned

Applicant’s surname

Applicant’s name

Applicant’s tax code

Applicant’s date of birth

Applicant’s residence (Enter full address)

Country of residence

Nationality

Applicant’s telephone number

Applicant’s E-mail

Applicant’s Identity Document

Any other attachment

Aware that pursuant to art. 76 of DPR 445/2000 the release of false declarations is punished according to the Criminal Code and special laws on the matter, on his/her own responsability

DECLARES

That he/she is temporarily domiciled in:

City

Street/Square…

N°

At

Together with his/her relative

Relatives

For reasons of

School/University name

Type of contract

Company name

Employment contract until

Chamber of Commerce registration number

INPS/INAIL position number

Other association/register

Medical certificate

For more than 3 - less than 12 months

From

To

Knowing that his/her Health Authority and City Hall of residence will be informed of his/her registration to Aulss 3 Serenissima

ASKS

temporary registration as non-resident citizen for himself or for his/her dipendent family members

Doctor 1

Doctor 2

For his/her under-14 CHILDREN

Pediatrician 1

Pediatrician 2

UNDERTAKES

To promptly inform the Health Authority about any change of domicile or an early return to his/her city of residence, knowing that his/her temporary registration will cease automatically at expiry date and may be renewed by sending a new application proving that the requirements are still fulfilled.

DECLARATION ACCORDING TO PRIVACY REGULATION

I have read the privacy policy on personal and health data treatment in AULSS 3 Internet site at the following link https://www.aulss3.veneto.it/privacy and I agree to my personal data treatment for administrative purposes, according to the European Regulation (GDPR n. 2016/679) and Italian Privacy Code (D.Lgs. n. 196/2003, as amended and supplemented by D.L. n. 101/2018).

READ AND AGREED

TEMPORARY REGISTRATION for domiciled citizens