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Spett.

le UNIONE BARRACELLI 
Via Padre Carboni 2 – 07040 Bessude (SS) 
email: ub@unione‐barracelli.it 
fax: 079 0971177 
cell.: 342 3801717 
 
 

 

 
 
 
 
DOMANDA D’ISCRIZIONE ALL’ASSEMBLEA RAPPRESENTATIVA DENOMINATA “UNIONE BARRACELLI” 
 
 
 
Io  sottoscritto  ____________________________________________________________________ 
residente a _______________________________ in via _____________________________ n° ___ 
modalità di contatto telefonica _________________________ email ________________________ 
COMANDANTE della Compagnia dei Barracelli di ________________________________________ 
 

  CHIEDO 

di iscrivermi all’Assemblea rappresentativa denominata “Unione Barracelli” ai sensi dell’art. 5 dello 
Statuto della stessa. 
ALLEGO 
alla  presente  l’elenco  dei  componenti  della  suddetta  Compagnia  che  chiedono  l’iscrizione  alla 
medesima “Unione Barracelli”. 
 
A tale scopo e con la presente i firmatari autorizzano “Unione Barracelli” a rappresentarli in tutte 
le sedi individuate dall’art. 2 dello Statuto, dichiarano inoltre di avere ricevuto le informazioni di 
cui all’art. 13 del D.lgs. n. 196/2003, in particolare riguardo ai diritti ad essi riconosciuti dalla legge 
ex art. 7 D.lgs. n. 196/2003 e acconsentono al trattamento dei miei dati personali al solo scopo di 
ricevere comunicazioni da “Unione Barracelli”. 
 
                       Luogo e data                                                                            Firma del CAPITANO 
 
_________________________________                                _________________________________ 

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Segue l’elenco dei componenti della Compagnia (si prega di scrivere in stampatello): 
 
COGNOME 

NOME 

RUOLO (grado, qualifica*)  EMAIL 

FIRMA 

__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
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__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
* indicare se si ricopre la qualifica di segretario o vice comandante. 

-2-

Segue l’elenco dei componenti della Compagnia (si prega di scrivere in stampatello): 
 
COGNOME 

NOME 

RUOLO (grado, qualifica*)  EMAIL 

FIRMA 

__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
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__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
* indicare se si ricopre la qualifica di segretario o vice comandante. 

-3-

Segue l’elenco dei componenti della Compagnia (si prega di scrivere in stampatello): 
 
COGNOME 

NOME 

RUOLO (grado, qualifica*)  EMAIL 

FIRMA 

__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
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__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
* indicare se si ricopre la qualifica di segretario o vice comandante. 

-4-

Segue l’elenco dei componenti della Compagnia (si prega di scrivere in stampatello): 
 
COGNOME 

NOME 

RUOLO (grado, qualifica*)  EMAIL 

FIRMA 

__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
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__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
* indicare se si ricopre la qualifica di segretario o vice comandante. 

-5-

Segue l’elenco dei componenti della Compagnia (si prega di scrivere in stampatello): 
 
COGNOME 

NOME 

RUOLO (grado, qualifica*)  EMAIL 

FIRMA 

__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
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__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
* indicare se si ricopre la qualifica di segretario o vice comandante. 

-6-

Segue l’elenco dei componenti della Compagnia (si prega di scrivere in stampatello): 
 
COGNOME 

NOME 

RUOLO (grado, qualifica*)  EMAIL 

FIRMA 

__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
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__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
* indicare se si ricopre la qualifica di segretario o vice comandante. 

-7-

Segue l’elenco dei componenti della Compagnia (si prega di scrivere in stampatello): 
 
COGNOME 

NOME 

RUOLO (grado, qualifica*)  EMAIL 

FIRMA 

__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
* indicare se si ricopre la qualifica di segretario o vice comandante. 

-8-

Segue l’elenco dei componenti della Compagnia (si prega di scrivere in stampatello): 
 
COGNOME 

NOME 

RUOLO (grado, qualifica*)  EMAIL 

FIRMA 

__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
* indicare se si ricopre la qualifica di segretario o vice comandante. 

-9-

Segue l’elenco dei componenti della Compagnia (si prega di scrivere in stampatello): 
 
COGNOME 

NOME 

RUOLO (grado, qualifica*)  EMAIL 

FIRMA 

__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
* indicare se si ricopre la qualifica di segretario o vice comandante. 

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Segue l’elenco dei componenti della Compagnia (si prega di scrivere in stampatello): 
 
COGNOME 

NOME 

RUOLO (grado, qualifica*)  EMAIL 

FIRMA 

__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
__________________________  _______________________________ ______________________ __________________________________________ 
* indicare se si ricopre la qualifica di segretario o vice comandante. 

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