[Translator’s notes appear in square brackets]

[Personal information has been redacted.]


Office -----

Number -----

Date -----

Enclosure -----



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]