Il/La sottoscritto/a ________________________________________________________________
nato/a _________________________________________________ il _______________________
residente in via ____________________________________________________ CAP __________
città _____________________________________________________________ Prov. _________
DELEGA
il/la sig./sig.ra ___________________________________________________________________
nato/a _________________________________________________ il _______________________
residente in via ____________________________________________________ CAP __________
città _____________________________________________________________ Prov. _________
a: (indicare il tipo di operazione per cui si effettua la delega) ______________________________________
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Il delegante
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(luogo e data) (firma)