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        <div id="content-top1">Page 65 - Manuale ECM</div>
        <div id="content-top2">P. 65</div>
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    <pre style="white-space:pre-line"><code>Da inviare sul portale COGEAPS salvo diversa    ALLEGATO VIII
indicazione del proprio Ordine di appartenenza

                       DOMANDA DI RICONOSCIMENTO DI CREDITI ECM
                                          PER AUTOFORMAZIONE

Il/la sottoscritto/a _________________________________________________________________
C.F. ____________________________________________________________________________
nato/a a ______________________________________________ il _________________________

                                                      CHIEDE

il riconoscimento dei crediti ECM per attivitÃ  di autoformazione ai sensi del paragrafo 3.5 del
Manuale sulla formazione continua del professionista sanitario con la seguente attribuzione:

        Obiettivo formativo: ______________________ TABELLA A
        AttivitÃ  professionista:_____________________ TABELLA B
        Professione: _____________________________ TABELLA C
        Disciplina: ______________________________ TABELLA D

A tal fine, consapevole delle sanzioni penali previste dallâ€™art. 76 del d.P.R. 28/12/2000, n. 445 per
le ipotesi di falsitÃ  in atti e dichiarazioni mendaci, sotto la propria responsabilitÃ ,

                                                     DICHIARA

di aver svolto la seguente attivitÃ  di autoformazione:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
dal __/___/______ al __/___/______ per ________ ore totali

Allega alla presente (in formato .pdf):
    1. copia di un documento dâ€™identitÃ  in corso di validitÃ ;
    2. altro______________________________________________________________________
         __________________________________________________________________________

Presta il consenso al trattamento dei dati personali ai sensi dellâ€™artt. 13 e 14 del Regolamento
Europeo sul trattamento dei dati personali (Regolamento UE 2016/679 â€“ â€œGDPRâ€)

Data                                            Firma
                                                ________________
__/__/____
            Â 
Â </code></pre>
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