REVENUE STAMP 
€ 16,00
(only if applicable)   

To the Rector
of the University of Pisa

Directorate for Education, Students Affairs and Internationalisation 
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
 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 scholarship grant/stipend amount		
□	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