[Translator’s notes appear in square brackets]

[Personal information has been redacted.]



Islamic Republic of Iran

Ministry of Education

Department of Education, Tehran


Office. -------

Date. -------

Number. -------

Enclosure. -------


In the Name of God,

You must answer the following questions with complete truthfulness.


  1. First name ------- Last name ------- Father’s name ------ Birth certificate number ------ Date of birth ------ Registration number ------
  2. Are your father and mother Baha’is?
  3. Are you a believer in the Baha’i sect?
  4. How many years have you been a follower of this faith?
  5. Do you speak about your faith in your classroom?
  6. Who among your relatives and kindred are followers of the Baha’i faith?
  7. Are you willing to recant your faith?
  8. Is there any other information you wish to add?



Place for signature