As a moderator psychologist

PERSONAL INFORMATION FORM FOR MODERATORS - PSYCHOLOGISTS Name Surname Domicile:   Adress Town Province Postal code Residence: if different from domicile Address Town Province Postal code Place of birth Date of birth   gg/mm/aaaa Education qualification Current occupation Telephone Cell-phone Fax E-mail Personal tax code VAT position Degree in psychology University of Area of specialisation Member of Register Availability Days per week no. of days: Consecutive days   Evening hours To travel     Previous experience:   Individual interviews Conducting focus groups Conducting creative groups     Institutes with which you have collaborated:     Additional information:     I hereby authorise the company Sinaptica s.r.l. to use my personal data, in accordance with Italian Law No. 196, of 30 June 2003.

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