[PROVISIONAL TRANSLATION FROM PERSIAN]
[Translator’s notes appear in square brackets]
[Personal information has been redacted.]
I, the undersigned, ----, surname ----, son/daughter of ----, rank ----, guild ----, [Baha’i] ID number----, resident/native of ----, birth certificate number ----, issued in ----, a member of the illegal Baha’i sect, declare that I have never engaged in any activities in the area of propaganda, fortification, and promotion of this sect and its related institutions, and shall never in the future engage in such activities that are against the Islamic Republic of Iran. In the event that I breach this undertaking, the government of the Islamic Republic has the right to make any decisions, such as termination of [my] salary, benefits, and/or claim reimbursement of salaries, [etc.]. And I waive the right to object to any such consequences.
Address: City ----, Street ----, Lane ---- [illegible][Number]