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src="./Richiesta%20di%20adesione%20modificata_file/image002.jpg" v:shapes="_x0000_s1026"></span></span><![endif]><b><span
style='font-family:Verdana'>RICHIESTA DI ADESIONE ALL'ASSOCIAZIONE APEIRON<o:p></o:p></span></b></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>Spett.le "APEIRON" c/o Dip. di Meccanica e Tecnologie Industriali<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><span style="mso-spacerun: yes"> </span>Università degli Studi di Firenze<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>Via S. Marta, 3 – 50139 FIRENZE</span></pre></td>
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<p class=MsoNormal align=center style='text-align:center'><span
style='display:none;mso-hide:all'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></p>
<div align=center>
<table border=0 cellspacing=0 cellpadding=0 width=775 style='width:465.0pt;
mso-cellspacing:0cm;mso-padding-alt:6.0pt 6.0pt 6.0pt 6.0pt'>
<tr>
<td style='padding:6.0pt 6.0pt 6.0pt 6.0pt'><pre><b><span style='font-family:
Verdana'>RICHIESTA DI ADESIONE ANNO 2003-2004</span></b><span
style='font-family:Verdana'><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>In riferimento alla Vs. proposta di adesione all'Associazione <b>APEIRON</b>, visti lo statuto ed il regolamento interno, chiediamo di essere ammessi come Soci.<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>Categoria socio (segnare con una X la categoria prescelta)<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><span style='mso-tab-count:1'> </span>[...]<span style="mso-spacerun: yes"> </span>Ordinario<span
style='mso-tab-count:1'> </span>Euro<span style='mso-tab-count:1'> </span><span style="mso-spacerun: yes"> </span>50,00<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><span style='mso-tab-count:1'> </span>[...]<span style="mso-spacerun: yes"> </span>Ridotto<span
style='mso-tab-count:1'> </span>Euro<span style='mso-tab-count:1'> </span><span style="mso-spacerun: yes"> </span>15,00<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><span style='mso-tab-count:1'> </span>[...]<span style="mso-spacerun: yes"> </span>Collettivo<span
style='mso-tab-count:1'> </span>Euro<span style='mso-tab-count:1'> </span>250,00<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>provvedendo fin d'ora a corrispondere la relativa quota di adesione per l'anno 2003-2004 pari a<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>Euro [..............],(...............................................................................)<o:p></o:p></span></pre><pre><span
style='font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Verdana'>(riportare il valore della quota esente da I.v.a. in cifre ed in lettere)</span><span
style='font-family:Verdana'> <o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>a mezzo del pagamento:<o:p></o:p></span></pre><pre><span
style='font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Verdana'>(segnare con una X il sistema di pagamento utilizzato)</span><span
style='font-family:Verdana'><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><span style='mso-tab-count:1'> </span>[...]<span
style='mso-tab-count:1'> </span></span><span style='font-size:9.0pt;
mso-bidi-font-size:10.0pt;font-family:Verdana'>in contanti;<o:p></o:p></span></pre><pre><span
style='font-size:9.0pt;mso-bidi-font-size:10.0pt;font-family:Verdana'><span
style='mso-tab-count:1'> </span>[...]<span style='mso-tab-count:
1'> </span>in assegno non trasferibile intestato a : Gaetano Cascini/Sergio Lorenzi;<o:p></o:p></span></pre><pre><span
style='font-size:9.0pt;mso-bidi-font-size:10.0pt;font-family:Verdana'><span
style='mso-tab-count:1'> </span>[...]<span style='mso-tab-count:
1'> </span>in accredito bancario diretto sul <b>c/c n° </b></span><span
style='mso-bidi-font-family:Arial'>420373</span><span style='font-size:9.0pt;
mso-bidi-font-size:10.0pt;font-family:Verdana'> intestato a <b>: <o:p></o:p></b></span></pre><pre><b><span
style='font-size:9.0pt;mso-bidi-font-size:10.0pt;font-family:Verdana'><span
style='mso-tab-count:2'> </span></span></b><span
style='font-size:9.0pt;mso-bidi-font-size:10.0pt;font-family:Verdana'>Gaetano Cascini, Sergio Lorenzi<b><o:p></o:p></b></span></pre><pre><span
style='font-size:9.0pt;mso-bidi-font-size:10.0pt;font-family:Verdana'><span
style='mso-tab-count:2'> </span>Banca FINECO, <o:p></o:p></span></pre><pre><span
style='font-size:9.0pt;mso-bidi-font-size:10.0pt;font-family:Verdana'><span
style='mso-tab-count:2'> </span>Cod. ABI: </span><span
style='mso-bidi-font-family:Arial'>03015</span><span style='font-size:9.0pt;
mso-bidi-font-size:10.0pt;font-family:Verdana'> - CAB: </span><span
style='mso-bidi-font-family:Arial'>03200</span><span style='font-size:9.0pt;
mso-bidi-font-size:10.0pt;font-family:Verdana'> - CIN: P<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>Indichiamo di seguito i nostri dati:<o:p></o:p></span></pre><pre
style='margin-top:6.0pt'><span style='font-family:Verdana'>.........................................................................................................<o:p></o:p></span></pre><pre><span
style='font-size:8.0pt;mso-bidi-font-size:10.0pt;font-family:Verdana'>(denominazione Ente/Società ecc. o nome e cognome richiedente)</span><span
style='font-family:Verdana'><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre
style='line-height:150%'><span lang=PT-BR style='font-family:Verdana;
mso-ansi-language:PT-BR'>Via<span style="mso-spacerun: yes"> </span>.......................................................................................... <span
style='mso-tab-count:1'> </span></span><span style='font-family:Verdana'>Nº .............<o:p></o:p></span></pre><pre
style='line-height:150%'><span style='font-family:Verdana'>Città ...................................................<span
style='mso-tab-count:1'> </span></span><span lang=EN-GB style='font-family:
Verdana;mso-ansi-language:EN-GB'>C.A.P. ..........................<span
style='mso-tab-count:1'> </span></span><span style='font-family:Verdana'>Prov<span style="mso-spacerun: yes"> </span>.........<o:p></o:p></span></pre><pre
style='line-height:150%'><span style='font-family:Verdana'>Tel<span style="mso-spacerun: yes"> </span>..................................................<span
style='mso-tab-count:1'> </span>Fax:<span style="mso-spacerun: yes"> </span>...............................................<o:p></o:p></span></pre><pre
style='line-height:150%'><span style='font-family:Verdana'>E-mail:................................................<span
style='mso-tab-count:1'> </span>WWW:...............................................<o:p></o:p></span></pre><pre
style='line-height:150%'><span style='font-family:Verdana'>P.Iva<span style="mso-spacerun: yes"> </span>.................................................<span
style='mso-tab-count:1'> </span>C.F.<span style="mso-spacerun: yes"> </span>.................................................<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>Nell'attesa della Vs. formale accettazione della presente richiesta, nonché della ricevuta<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>riscontrante l'incasso della quota versata, porgiamo distinti saluti.<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>Data: .............................<span
style='mso-tab-count:3'> </span>Firma: ................................................<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>Autorizziamo fin da ora l'Associazione a pubblicare su una pagina riservata ai Soci del sito Web della stessa i dati (Nominativo e indirizzo e-mail di contatto) contenuti nella presente, e ad utilizzarli per le comunicazioni e le attività dell’Associazione rivolte ai Soci.<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>Data: .............................<span
style='mso-tab-count:3'> </span>Firma: ................................................</span></pre></td>
</tr>
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<p class=MsoNormal><![if !supportEmptyParas]> <![endif]><o:p></o:p></p>
<span style='font-size:12.0pt;font-family:"Times New Roman";mso-fareast-font-family:
"Times New Roman";mso-ansi-language:IT;mso-fareast-language:IT;mso-bidi-language:
AR-SA'><br clear=all style='mso-special-character:line-break;page-break-before:
always'>
</span>
<p class=MsoNormal align=center style='text-align:center'><![if !supportEmptyParas]> <![endif]><o:p></o:p></p>
<div align=center>
<table border=0 cellspacing=0 cellpadding=0 width=775 style='width:465.0pt;
mso-cellspacing:0cm;mso-padding-alt:6.0pt 6.0pt 6.0pt 6.0pt'>
<tr>
<td style='padding:6.0pt 6.0pt 6.0pt 6.0pt'><pre><b><span style='font-family:
Verdana'>INFORMAZIONI AGGIUNTIVE PER I SOCI COLLETTIVI<o:p></o:p></span></b></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>Come da statuto Apeiron, indichiamo di seguito i nominativi e i dati delle persone facenti parte della nostra organizzazione che godranno delle agevolazioni dei Soci ordinari Apeiron.<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>La prima persona dell’elenco sarà il nostro rappresentante con diritto di voto.<o:p></o:p></span></pre><pre><span
style='font-family:Verdana'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></pre><pre><span
style='font-family:Verdana'>La firma in calce ad ogni singolo nominativo autorizza l'Associazione a pubblicare su una pagina riservata ai soci del sito Web della stessa i dati (Nominativo e indirizzo e-mail di contatto) contenuti nella presente, e ad utilizzarli per le comunicazioni e le attività dell’Associazione rivolte ai Soci.</span></pre></td>
</tr>
</table>
</div>
<p class=MsoNormal><span style='font-size:10.0pt;mso-bidi-font-size:12.0pt'><![if !supportEmptyParas]> <![endif]><o:p></o:p></span></p>
<table border=0 cellspacing=0 cellpadding=0 width=780 style='width:468.0pt;
margin-left:12.5pt;border-collapse:collapse;mso-padding-alt:0cm 3.5pt 0cm 3.5pt'>
<tr>
<td width=382 valign=top style='width:228.9pt;padding:0cm 3.5pt 0cm 3.5pt'>
<p class=MsoNormal style='margin-top:6.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Socio 1 - Rappresentante<o:p></o:p></span></b></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Nome
..................................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Cognome
.............................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Città
..............................<span style="mso-spacerun: yes"> </span></span><span
lang=PT-BR style='font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:
Verdana;mso-ansi-language:PT-BR'>Prov ..........<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span lang=PT-BR
style='font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Verdana;
mso-ansi-language:PT-BR'>Tel<span style='mso-tab-count:1'> </span>..................................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span lang=PT-BR
style='font-size:10.0pt;mso-bidi-font-size:12.0pt;font-family:Verdana;
mso-ansi-language:PT-BR'>Fax<span style='mso-tab-count:1'> </span>..................................................<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:6.0pt'><span lang=PT-BR
style='mso-bidi-font-size:12.0pt;font-family:Verdana;mso-ansi-language:PT-BR'>E-mail
..................................................</span><span lang=PT-BR
style='font-size:8.0pt;mso-bidi-font-size:12.0pt;font-family:Verdana;
mso-ansi-language:PT-BR'><o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:12.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>Firma per autorizzazione uso dei dati<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:6.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>...........................................................<o:p></o:p></span></p>
</td>
<td width=399 valign=top style='width:239.1pt;padding:0cm 3.5pt 0cm 3.5pt'>
<p class=MsoNormal style='margin-top:6.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Socio 2<o:p></o:p></span></b></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Nome
..................................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Cognome
.............................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Città
..............................<span style="mso-spacerun: yes"> </span>Prov
..........<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Tel<span style='mso-tab-count:
1'> </span>..................................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Fax<span style='mso-tab-count:
1'> </span>..................................................<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:6.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>E-mail
..................................................<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:12.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>Firma per autorizzazione uso dei dati<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:6.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>...................................................<o:p></o:p></span></p>
</td>
</tr>
<tr>
<td width=382 valign=top style='width:228.9pt;padding:0cm 3.5pt 0cm 3.5pt'>
<p class=MsoNormal style='margin-top:6.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Socio 3<o:p></o:p></span></b></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Nome
..................................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Cognome
.............................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Città
..............................<span style="mso-spacerun: yes"> </span>Prov
..........<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Tel<span style='mso-tab-count:
1'> </span>..................................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Fax<span style='mso-tab-count:
1'> </span>..................................................<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:6.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>E-mail
..................................................<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:12.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>Firma per autorizzazione uso dei dati<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:6.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>...........................................................<b><o:p></o:p></b></span></p>
</td>
<td width=399 valign=top style='width:239.1pt;padding:0cm 3.5pt 0cm 3.5pt'>
<p class=MsoNormal style='margin-top:6.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Socio 4<o:p></o:p></span></b></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Nome
..................................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Cognome .............................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Città
..............................<span style="mso-spacerun: yes"> </span>Prov
..........<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Tel<span style='mso-tab-count:
1'> </span>..................................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Fax<span style='mso-tab-count:
1'> </span>..................................................<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:6.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>E-mail
..................................................<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:12.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>Firma per autorizzazione uso dei dati<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:6.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>...........................................................<b><o:p></o:p></b></span></p>
</td>
</tr>
<tr>
<td width=382 valign=top style='width:228.9pt;padding:0cm 3.5pt 0cm 3.5pt'>
<p class=MsoNormal style='margin-top:6.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Socio 5<o:p></o:p></span></b></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Nome
..................................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Cognome
.............................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Città
..............................<span style="mso-spacerun: yes"> </span><span
style="mso-spacerun: yes"> </span>Prov ..........<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Tel<span style='mso-tab-count:
1'> </span>..................................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Fax<span style='mso-tab-count:
1'> </span>..................................................<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:6.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>E-mail
..................................................<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:12.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>Firma per autorizzazione uso dei dati<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:6.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>...........................................................<b><o:p></o:p></b></span></p>
</td>
<td width=399 valign=top style='width:239.1pt;padding:0cm 3.5pt 0cm 3.5pt'>
<p class=MsoNormal style='margin-top:6.0pt'><b><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Socio 6<o:p></o:p></span></b></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Nome
..................................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Cognome
.............................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Città
..............................<span style="mso-spacerun: yes"> </span>Prov
..........<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Tel<span style='mso-tab-count:
1'> </span>..................................................<o:p></o:p></span></p>
<p class=MsoNormal style='margin-top:6.0pt'><span style='font-size:10.0pt;
mso-bidi-font-size:12.0pt;font-family:Verdana'>Fax<span style='mso-tab-count:
1'> </span>..................................................<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:6.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>E-mail
..................................................<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:12.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>Firma per autorizzazione uso dei dati<o:p></o:p></span></p>
<p class=MsoCommentText style='margin-top:6.0pt'><span style='mso-bidi-font-size:
12.0pt;font-family:Verdana'>...........................................................<b><o:p></o:p></b></span></p>
</td>
</tr>
</table>
<p class=MsoNormal><![if !supportEmptyParas]> <![endif]><o:p></o:p></p>
<p class=MsoNormal><![if !supportEmptyParas]> <![endif]><o:p></o:p></p>
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