[PROVISIONAL TRANSLATION FROM PERSIAN]

 

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

 

[questionnaire is in different languages]

[Emblem]

Islamic Republic of Iran

Bon

 

In the Name of God, the Exalted

VISA APPLICATION FORM for IRAN

 

[Place of photo]

Reference Number:

Passport No:

Issued at:

Valid until:

 

1. Surname:

2. First name(s):

3. Date and place of birth:

4. Profession:

5. Marital status:

6. Religion:

7. Country of origin:

8. Present citizenship, (and former citizenship, if different):

9. Name and citizenship of father:

10. Name and citizenship of mother:

11. Permanent address:

12. Are you a member of a [political] party?

13. What is the purpose of your visit to Iran?

14. How long do you wish to stay in Iran?

Please turn the page over

15. Have you visited this country before? If so when?

16. References in Iran:

17. Which other countries did you visit before?

18. Frontier (air or land):

19. Destination:

20. Address in Iran:

21. Telephone –Number:

22. Supplementary information:

I declare that the above information to be a full and true statement:

Date:

Personal signature: