To Roma Capitale Dipartimento Tutela Ambientale – Protezione Civile U.O. Gestione Verde Pubblico Piazza di Porta Metronia, 2 00183 Roma [email protected] REGISTRATION FORM “Dona un albero a Roma” (donate a tree to Rome) I undersigned __________________________________________________________________________________ born in (city and state) _________________________________________________________________________ on (date of birth) ______________________________________________________________________________ resident in (city and state) _________________________________________________________________________ address ____________________________________________________________________________________ Postcode ___________________ Tel ____________________________Mobile ______________________________ Fax _________________/ Email _____________________________________ @ ____________________________ DECLARE that I intend to take part in the “DONA UN ALBERO A ROMA” (donate a tree to Rome) initiative, for which purpose I, the undersigned, donate a total of _____________ tree/trees transfer the sum of € 250.00 per tree for a sum total of € _____________.00 as donation to Roma Capitale for purchase and maintenance of the tree/s donated. specify the area/areas (Municipio/Municipi, or administrative borough/s) in which the tree/s is/are to be located: nr. ____type1 _________ □ MUNICIPIO I nr. ____type _________ □ MUNICIPIO IX nr. ____type __________ □ MUNICIPIO II nr. ____type _________ □ MUNICIPIO X2 nr. ____type __________ □ MUNICIPIO III nr. ____type _________ □ MUNICIPIO XI nr. ____type __________ □ MUNICIPIO IV nr. ____type _________ □ MUNICIPIO XII nr. ____type __________ □ MUNICIPIO V nr. ____type _________ □ MUNICIPIO XIII nr. ____type __________ □ MUNICIPIO VI nr. ____type ________ □ MUNICIPIO XIV nr. ____type __________ □ MUNICIPIO VII nr. ____type _________ □ MUNICIPIO XV nr. ____type __________ □ MUNICIPIO VIII It is requested that the following dedicatory message accompany the donation (max. 140 characters) (include message if desired): ____________________________________________________________ _________________________________________________________________________________________ ___________________________ ____________________________________________________________________________________ I undersigned declare that I am aware that: in regard to the tree species selected, to ensure compatibility with the plant life assets present in the area selected, I must reach an agreement with the technical staff of the parks and gardens service, Servizio Giardini del Dipartimento Tutela Ambientale; planting shall take place at the agronomically appropriate time and season (autumn/fall-winter) for planting. Please find attached: □ a pdf format copy of a valid ID document; □ a copy of the receipt for payment3 by bank transfer totalling € 250.00 per tree, consisting in a donation made to Roma Capitale with specification of the reason for payment: “Adesione al progetto Dona un Albero a Roma” (participation in the “Give Rome a Tree” project). For the bank transfer to Roma Capitale, Tesoreria Comunale, capofila (reference bank) Unicredit S.p.A , Via Monte Tarpeo, 41, the procedure can be undertaken at any bank or post office (Banco Posta). The beneficiary’s bank data are as follows: Codice IBAN (IBAN code) National IBAN CIN ABI CAB C/C (current code account) IT 69 P 02008 05117 000400017084 BIC code (for transfers from abroad) SWIFT CODE UNCRITMM I undersigned issue AUTHORISATION that my name may be included in the Registro Donatori “Un Albero a Roma” (the “donate a tree to Rome” donors’ register) accessible on the Roma Capitale web portal: 1 To select the tree/s, users may access the photo gallery and find the corresponding code 2 This Municipio (admnistrative borough) has yet to decide whether it shall join the project, by means of a deliberation, Deliberazione Municipale, to this effect. 3 The contribution may instead be made by payment to the municipal treasury office, Tesoreria Comunale – via Monte Tarpeo, 41 YES NO I undersigned furthermore declare that: - in accordance with art. 47 seq. of the section, Titolo V, of the D.P.R. (presidential decree) of 28 December 2000 no. 445, I am aware of the criminal law consequences of misrepresentation and of drafting or use of false deeds as per art. 76 of the said decree; - I am aware, for the purposes of art. 13 of D. Lgs. (legislative decree) no. 196/2003, that the personal data collected shall be processed (also by electronic means) solely for the purposes of the procedures pertaining to the declaration herein; that the body responsible for the processing of the data is the parks and gardens operational unit, U.O. Gestione Verde Pubblico, in the person of the director thereof; and am aware of the provisions of art. 7 of D. Lgs. (legislative decree) no. 196/2003 pertaining to the rights relative to competence for, and access to, personal data and other rights. The application is undersigned by the applicant, has been scanned as a pdf file and has been sent, only by e-mail, with the attachments consisting in a copy of the receipt attesting to the bank transfer effected and a copy of the ID card, to the address [email protected] . Place ______________________, date ____/____/____ Applicant _________________________________________ .