TEMPORARY REGISTRATION for domiciled citizens
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:
Select an option
30010 - Campagna Lupia
30010 - Campolongo Maggiore
30010 - Camponogara
30014 - Cavarzere
30015 - Chioggia
30010 - Cona
30031 - Dolo
30032 - Fiesso dArtico
30030 - Fossò
30020 - Marcon
30030 - Martellago
30034 - Mira
30035 - Mirano
30033 - Noale
30030 - Pianiga
30020 - Quarto dAltino
30030 - Salzano
30036 - Santa Maria di Sala
30037 - Scorzè
30038 - Spinea
30039 - Stra
30121 - Venezia
30122 - Venezia
30123 - Venezia
30124 - Venezia
30125 - Venezia
30126 - Lido e Pellestrina
30132 - Venezia
30133 - Venezia
30135 - Venezia
30141 - Murano
30142 - Burano
30171 - Mestre Venezia
30172 - Mestre Venezia
30173 - Favaro Venezia
30174 - Chirignago Cipressina Trivignano Zelarino
30174 - Carpenedo Terraglio
30175 - Marghera Venezia
30176 - Marghera Venezia
30030 - Vigonovo
City
Street/Square…
N°
At
Together with his/her relative
Relatives
Surname
Name
Relationship
Tax code
Select an option
School / University
Work
Health
For reasons of
School/University name
Select an option
employee
self - employed
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
If registrating for the first time or renewing after 30 days, you must attach Your GP’s revocation which You may ask to the District Registry in Your city of residence (for those who have their residence and GP outside the Veneto Region)
Attach revocation
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
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