UNIVERSITÀ DEGLI STUDI DI BRESCIA
DIPARTIMENTO DI ECONOMIA E MANAGEMENT
Via San Faustino, 74/B - 25122 BRESCIA
Codice Fiscale 98007650173 - Partita IVA 01773710171

COST Action TD1306 New Frontiers of Peer
Review

Declaration for claim reimbursement

(to be filled and sent to cost.td1306cgs@unibs.it or uploaded to your claim on the e-

cost system)

Name and Surname: ________________________________________

Date and Place of Birth: ______________________________________

Full address of residence: ____________________________________

District	_______________________       ZipCode ______________

Country _______________

Phone number: _____________________________________________

Passport number ____________________
(please include a scanned copy of your pass)

Date:

Signature  	

Dip.to Economia e Management, Servizi Amministrativi – Via San Faustino, 74/B  25122 Brescia – cost.td1306cgs@unibs.it