DOMANDA D’ISCRIZIONE / APPLICATION FORM

Avvertenze: Compilare la domanda e spedire via Fax al +39 0362 222914 oppure via email a staff@concorsopozzoli.it Note: Please fill in the application form and send it by fax to +39 0362 222914 or by email at staff@concorsopozzoli.it

Cognome / Surname ____________________________________________________________________ Nome / First Name _____________________________________________________________________ Sesso / Gender M F Nazionalità / Nationality _________________________________________ Data di nascita / Date of Birth ______________ Luogo di nascita / Place of Birth _____________________ Residenza / State of residence Stato / State ___________________________________________________________________________ Via / Street _____________________________________ Città / City ______________________________ Telefono / Telephon_______________________________Fax____________________________________ cell./mobile______________________________________e-mail__________________________________ Domicilio / Domicile (se diverso dalla residenza /if different from the place of residence) dal 1.04 al 31.07.17 Stato / State ___________________________________________________________________________ Via / Street _____________________________________ Città / City ______________________________ Telefono / Telephone ____________________________________________________________________ e-mail ________________________________________________________________________________ Codice fiscale / Fiscal code _______________________________________________________________ (only for italian pianist) Accetto le condizioni del regolamento ed allego i documenti richiesti e la tassa di iscrizione. I agree to abide by the regulations of the competition and I enclose the document and the enrolment fee. Data / Date ________________________ Firma / Signature _____________________________________

I dati sono raccolti e conservati secondo la normativa italiana a tutela della privacy. Il documento informativo della normativa sulla tutela della privacy si può trovare sul sito del Concorso. Data are collected and stored according to the italian privacy law. The information memorandum on the protection privacy law can be found on the website of the Competition. Firma / Signature _____________________________________

CURRICULUM VITAE Cognome / Surname ____________________________________________________________________ Nome / First Name _____________________________________________________________________ Elenchi gli studi conseguiti / List your diplomas _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Elenchi gli insegnanti / List your teachers _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Elenchi gli eventuali premi vinti / List your prizes _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Firma / Signature _____________________________________

PROGRAMMA PER LE PROVE / REPERTOIRE

Durata Edizione Length Edition

Prima prova eliminatoria / First Round _______________ ________________________________________ _________ __________ _______________ ________________________________________ _________ __________ _______________ ________________________________________ _________ __________ Seconda prova eliminatoria / Second Round

_______________ _________________________________________ __________ __________ _______________ _________________________________________ __________ __________

E. Pozzoli Studi di media difficoltà n. ____________________ _________ __________ E. Pozzoli Studi a moto rapido n._______________________ _________ __________ E. Pozzoli Studi sulle note ribattute n. ___________________ _________ __________ Terza prova (semifinale) / Third Round (semi-final) _______________ ________________________________________ _________ __________ _______________ ________________________________________ _________ __________ _______________ ________________________________________ _________ __________ E. Pozzoli da “Riflessi del mare” _______________________ _________ __________ Quarta prova (finale con Orchestra) / Fourth Round (final with Orchestra) _______________ ________________________________________ _________ __________ SPAZIO RISERVATO ALLA GIURIA / SPACE RESERVED TO THE JURY _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

PRENOTAZIONE ALLOGGIO / BOOKING ACCOMODATION

Richiedete l’alloggio ? / Do you require accomodation? sì / yes no

Hotel (prenotazione e spese a carico del concorrente. Le spese di hotel verranno pagate dalla Segreteria solo dopo l’ammissione alla semifinale) (booking and expenses paid by the competitors . The hotel expenses will be paid by the Secretariat only after the admittance to the semi-final) Famiglia / Family (gratis / free) Solo per chi sceglie la famiglia: / Only for those who choose a family: (Queste informazioni serviranno per la famiglia che vi ospiterà / These information will be used by your host family) A partire da / from ______________________________________________________________________ (1 giorno prima per i concorrenti che arrivano dalla UE e 2 giorni prima per concorrenti che arrivano da paesi extra UE)/(1 day before the competition for EU contestants and 2 days before for non-EU) Lingue parlate / spoken languages _________________________________________________________ Allergie / Allergies ______________________________________________________________________ Fumatore? / Are you a smoker? ____________________________________________________________ Richieste o preferenze particolari / Special requests or preferences ________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Altro / Anything else _____________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Data / Date ________________________ Firma / Signature _____________________________________