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. _________

(indicare il tipo di operazione per cui si effettua la delega) 
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		Il delegante	
	__________________________	______________________________
	(luogo e data)	(firma)

N.B.: allegare fotocopia del documento di identità del delegante