[PROVISIONAL TRANSLATION FROM PERSIAN]
[Translator’s notes appear in square brackets]
[Personal information has been redacted.]
Islamic Republic of Iran
Ministry of Education
Department of Education, Tehran Province
In the Name of God
It is essential to answer the following questions with utmost honesty.
Name ----- Surname ----- Father's name ----- Birth certificate number ----- Year of birth -----
Baha'i registration number -----
2- Are your parents Baha'is?
3- Are you a follower of the Baha'i sect?
4- How many years have you been following this ideology?
5- Do you discuss your beliefs in classes?
6- Which of your close relatives and friends are followers of Bahaism?
7- Are you ready to recant this ideology?
8- Write any other information you deem necessary
Place of [signature]