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MODULO DICH.

MODULO DICH.
DICHIARAZIONE DI PRESENZA/DECLARATION DE PRESENCE/
DECLARATION OF PRESENCE/DECLARATION DE ENTRADA/
AUFENTHALTSERKLARUNG

Cognome/Nom/Surname/Apellido/Nachname___________________________________________
________________________________________________________________________________
Nome/Prnom/Name/Nombre/Vorname_______________________________________________
________________________________________________________________________________
Data di nascita/Lieu de naissance/Place of birth/Fecha de nacimento/ Geburtsdatum
________/_______/________
Sesso/Sexe/Gender/Sexo/ Geschlecht

M/H

F/W

Luogo di nascita/Lieu de naissance/Place of birth/Lugar de nacimiento/ Geburtsort


________________________________________________________________________________
Cittadinanza/Nationalit/Nationality/Nacionalidad/ Staatsangehrigkeit_______________________
Tipo di documento/Pice didentit/Type of document/Tipo de documento/ Art des Dokuments
______________________________________________N________________________________

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DICHIARAZIONE DI PRESENZA/DECLARATION DE PRESENCE/


DECLARATION OF PRESENCE/DECLARATION DE ENTRADA/
AUFENTHALTSERKLARUNG
Cognome/Nom/Surname/Apellido/Nachname___________________________________________
________________________________________________________________________________
Nome/Prnom/Name/Nombre/Vorname_______________________________________________
________________________________________________________________________________
Data di nascita/Lieu de naissance/Place of birth/Fecha de nacimento/ Geburtsdatum
________/_______/________
Sesso/Sexe/Gender/Sexo/ Geschlecht

M/H

F/W

Luogo di nascita/Lieu de naissance/Place of birth/Lugar de nacimiento/ Geburtsort


________________________________________________________________________________
Cittadinanza/Nationalit/Nationality/Nacionalidad/ Staatsangehrigkeit_______________________
Tipo di documento/Pice didentit/Type of document/Tipo de documento/ Art des Dokuments
______________________________________________N________________________________

Rilasciato da/Dlivre par/Issued by/Expedido por/Ausgestellt von__________________________

Rilasciato da/Dlivre par/Issued by/Expedido por/Ausgestellt von__________________________

Valido dal/Valable de/Valid from/Con validez desde el/Gltig von


Al/Au/To/Hasta el/Bis ________/_______/_____________

Valido dal/Valable de/Valid from/Con validez desde el/Gltig von


Al/Au/To/Hasta el/Bis ________/_______/_____________

______/______/___________

______/______/___________

Stato di provenienza/Pays de provenance/Country of origin/Pais de procedencia/Herkunftsland


________________________________________________________________________________

Stato di provenienza/Pays de provenance/Country of origin/Pais de procedencia/Herkunftsland


________________________________________________________________________________

Tipo di Visto (per il familiare straniero)/Model de Visa (pour les parents trangers)/Art Visum (fr den
auslndischen familienangehorigen)/Kind of Visa (for a foreign familiar)/Visado de entrada por familiar
extranjeros ______________________________________________________________________

Tipo di Visto (per il familiare straniero)/Model de Visa (pour les parents trangers)/Art Visum (fr den
auslndischen familienangehorigen)/Kind of Visa (for a foreign familiar)/Visado de entrada por familiar
extranjeros ______________________________________________________________________

Recapito in Italia/Adresse el Italie/Address in Italy/Domicilio en Italia/Anschrift in Italien:


Via-Piazza-Corso/Rue-Place-Avenue/Calle-Plaza-Avenida/Street-Square-Avenue/Strae________
_____________________________________________________________N_________________

Recapito in Italia/Adresse el Italie/Address in Italy/Domicilio en Italia/Anschrift in Italien:


Via-Piazza-Corso/Rue-Place-Avenue/Calle-Plaza-Avenida/Street-Square-Avenue/Strae________
_____________________________________________________________N_________________

Comune/Ville/City/Localidad/Gemeinde______________________________________________

Comune/Ville/City/Localidad/Gemeinde______________________________________________

Provincia/Province/Provinz_________________________________________________________

Provincia/Province/Provinz_________________________________________________________

Data di ingresso/Date dentre/Entry date/Fecha de entrada/Einreisedatum____________________

Data di ingresso/Date dentre/Entry date/Fecha de entrada/Einreisedatum____________________

Durata del soggiorno/Dure du sjour/Duration of stay/Duracin de la estancia/Dauer des


Aufenthalts:gg/jours/days/dias/tage___________________________________________________

Durata del soggiorno/Dure du sjour/Duration of stay/Duracin de la estancia/Dauer des


Aufenthalts:gg/jours/days/dias/tage___________________________________________________

Data/Date/Fecha/Datum ________/_________/___________

Data/Date/Fecha/Datum ________/_________/___________

Firma/Signature/Unterschrift __________________________________________

Firma/Signature/Unterschrift __________________________________________

Timbro Ufficio/Cachet du service/Official Stamp/Stempel dienststelle

Timbro Ufficio/Cachet du service/Official Stamp/Stempel dienststelle