Certificate Replacement Declaration Form

(Article 46 of Presidential Decree No. 445 of 28 December 2000)

and/or
Declaration form instead of the affidavit
(Article 47 of Presidential Decree No. 445 of 28 December 2000)

The undersigned……………………………………………. born in …………………… province

of…….on………………….. residing at…………………….……………………………… province
of ………. Zip Code…………….. Street…………………………………….. number……………

DECLARES

1) pursuant to Articles 46, 47 and 38 of Presidential Decree No. 445 of 28.12.2000, to be in

possession of the following
qualifications: ……………...…………..………………………………………………………..
obtained at: …………….......................................................................................................
on:…………………..…. with the grade of: ……………………….

2) pursuant to Articles 47, 38 and 19 of Presidential Decree No. 445 of 28.12.2000, that the
photocopies relating to the qualifications attached to the application (publications, certifications,
degree, etc.), conform to the originals:
(to be completed where the qualifications are required in Annex 1)
a) ……………………………………………………………………………...………………….
b) ……………………………………………………………………………...………………….
c) ……………………………………………………………………………...………………….

The undersigned declares that s/he knows the penal sanctions resulting from false statements,
training and/or use of false documents referred to in Article 76 of the Presidential Decree of
28.12.2000, No. 445, as well as the forfeiture of any benefits resulting from the measure of false
statements prepared by Article 75 of the Presidential Decree of 28.12.2000, number 445.
The undersigned, on pain of nullity of the declaration, attaches the photocopy of a valid identity
document.

Date ………………………..

The Declarant
………………………………