REVENUE STAMP 
€ 16,00
(only if applicable)   

To the Rector
of the University of Pisa

Educational and Internationalisation Services’ Office
Largo Pontecorvo 3, 56127 PISA

Certificate request
Space reserved for the office	
	
Reference n. ______________ of _____________		

Student/PhD ID NUMBER		
Surname and Name     		
Place and date of birth		
Permanent Address
 (Street/Square name, number, postcode, city)  		
Phone number, mobile number			
e-mail		

To this aim, I hereby declare to be
- aware that Public Administration offices or private providers on behalf of public services are not entitled to demand nor accept this certificate (under Law n. 183 art. 15 of 12/11/2011)  
- informed that giving false statements is an offence under the Italian Penal Code and special laws related, in accordance with the Presidential Decree DPR no. 445/2000 art. 46
I request the issuing of a certificate as here specified

 PhD 	 Specialization School    Post Graduate Vocational Course
 TFA/PAS/Special Education Course
Course title _________________________________________________________________________
 Other ____________________________________________________________________________
 For authorized purposes abroad 	 in English Language 
 on plain paper, for one of the purposes stated in Table B annexed to Presidential Decree DPR no. 642/1972, aware of the informative on revenue stamp exemption;
 on plain paper, for any judicial proceeding the applicant is subject to (pursuant to the Presidential Decree DPR no. 115/2002, art.1)
 on plain paper for other purposes_____________________________________________________ /indicate the intended purposes and the related provision on revenue stamp exemption
 with revenue stamp

	Type	No.	
□	Enrolment certificate		
□	Enrolment certificate including the study grant amount (only for PhD)		
□	Qualification - certificate		
□	Qualification with the title of the thesis - certificate		
□	Other (please specify the data to include)
_______________________________________________________________________________________ 		

In addition, I request that the certificate will be: [Please tick one of the followings] 	
□	sent in attachment in reply to the ticket request applied on the “virtual desk”	
□	sent via fax to the following number _____________________________	
□	sent in attachment via certified e-mail system (Posta Elettronica Certificata - PEC) to the following account ____________________________	
□ 	sent to the following address:	
	City ____________________________________________________________________ prov. __________ postcode ____________ Street/Square _____________________________________________________ num._______	
□ 	personally collected at the office reception	
□ 	collected by Mr./Ms  at the office reception _______________________________________________ 
born in (place of birth) _________________________________________________________   
on (date of birth) ________________________ _________	

In the event of request for “certificate with revenue stamp” 
Please note: For the issuing of certificates with revenue stamp, the applicant is required to personally buy and provide the front office desk with a revenue stamp for each certificate or forward them by ordinary mail along with the “revenue stamp” transmission form.

 I hereby declare to be aware that the certificates could be issued only prior the relevant revenue stamps are provided or mailed to the front office desk 

I Attach no. ______________________ revenue stamps
(Only when submitting or mailing to the front office desk the certificate request)	

________________________	                                               __________________________________
	                Place and date 	                                                        Signature