[PROVISIONAL TRANSLATION FROM PERSIAN]
[Translator’s notes appear in square brackets]
[Personal information has been redacted.]
In the name of God
From: The Security Office of the Management Education Department, Shiraz, Region 1
To: All the urban and rural education units * Siyakh Darnigoun [one of the localities in Shiraz] representative
Date: 30/9/1385 [21 December 2006]
With respect, further to the circular letter number 17/1067/M – 15/7/1385, the following form is submitted for recording the information of students who belong to religious minorities and the perverse Bahaism sect. We request that, after completion, it be returned to this office for necessary exploitations.
Security Office of the Education Department Management, Shiraz, Region 1
Registration form for information of the students of the city of Shiraz, Area 1, Region 1 * Academic year 1385–1386 [2006–2007]
1-Student’s personal information
Name: ----- Last Name: ----- Father’s name: -----
Date of Birth: ----- Identification Card Number: ----- Place of Issue: -----
Nickname: ----- Type of degree: ----- Name of Training Institute:
Class: ----- Branch: -----
Religion: Christian ----- Jew ----- Zoroaster ----- Perverse Bahaism sect -----
2- Information of family members:
[a table to fill in the name, surname, age, education, profession, and place of work of the father, mother and all the siblings]
If parents are self-employed, provide a detailed explanation.
3- Last year’s place of education: ----- City ----- Area ----- Region
4- Emergency telephone numbers:
Telephone number: ----- Name of the owner of the Telephone: Relationship to you:
5-If parents are deceased or divorced, provide the date.
6-If you use [pickup] services
Name of the driver: ----- Number of the [pickup] service:
7-If the parents are employed after retirement provide the exact place of work.
8-Telephone number of the place of work and cellular phone of parents:
Home Telephone Number: ----- Postal Code ----- Clear map to your house:
Name and last name of the manager of the educational institute
Signature of the manager and the stamp of the educational institute