Italian Language Application Form
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Application Form 2016
APPLICATION INSTRUCTIONS
RETURN COMPLETED FORM TO
Istituto Lorenzo de’ Medici – Italian Language Enrollment Office
The following are required to apply for the LdM Italian
E-mail:
ita@lorenzodemedici.it
Language Programs:
Via Faenza, 43
Application Form – completed and signed
50123 Florence, Italy
Proof of Payment
Tel. +39 055 28 73 60 / +39 055 28 72 03 Fax + 39 055 23 98 920
Copy of your passport
PERSONAL INFORMATION
Female
Last Name___________________________________________
First Name ___________________________
Male
Current University/College______________________________
Profession____________________________________________
Country of Citizenship___________________________________ First Language________________________________________
Date of Birth (dd/mm/yy) ________________________________
Passport Number______________________________________
City/State of Birth _____________________________________
Country of Birth________________________________________
Permanent Address___________________________________________________________________________________________
City ________________________________________________
Country______________________________________________
Postal Code__________________________________________
E-mail_______________________________________________
Phone / Fax__________________________________________
Mobile phone__________________________________________
EMERGENCY CONTACT
Name______________________________________________
Relationship__________________________________________
Phone / Mobile_______________________________________
E-mail________________________________________________
Have you previously studied at Lorenzo de’ Medici Institute?
Yes
No
How did you find out about our Programs?
Family/friend
LDM website
Istituto Italiano di Cultura
Student
Google Ad
Teacher
Other ___________________________________________________________________________________________________
PRIVACY POLICY
LdM is registered to hold your personal data in accordance with Italian Law 675/1996 and D.Lgs.196/2003 on privacy. This information will be used
for administrative purposes and will not be given to any third party. I hereby agree to comply with the above regulations and I authorize the use of my
personal information by Lorenzo de’ Medici.
I allow LdM exclusively to collect, publish and use for purposes of advertising and promotion that are not detrimental to my dignity or reputation:
1) my image in photographic, video or digital content; 2) my own writings, figurative works, music, art, and creative projects; 3) my name in
conjunction with interviews and statements in relation to LdM. I permanently waive all rights of compensation for the aforementioned content
generated in the period of enrollment at LdM, which may be reproduced either in its entirety or in part, in the form of any multimedia content, and
may be published on the following website
and/or in other domains related to LdM in Italy and abroad.
Student signature
Date
________________________________________________
_______________
Lorenzo de’ Medici – Florence, Tuscania, Rome
AP_IT_16 08.03.2016
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