[Translator’s notes appear in square brackets]

[Personal information has been redacted.]


In the Name of God


Name and Surname:

Birth certificate number:

Father’s name:

Date of Birth:

Date of Employment:

Last position:

Education level:


Number of Children:

Current wages and benefits:

Confirm your statement and sign each of the following: 

1 – In accordance with documents received from the Central Office of Documentation of the Islamic Republic, you have been identified as a member of the perverse Baha’i sect; should you have an explanation in this regard, put this in writing.

2 – In the event that members of your family or [other] relatives are affiliated with this sect, you are to provide their names and [contact] details in writing.

3 – State in writing your position in and your affiliation with the organization [and] your activities in the propagation of the Baha’i sect.

4 – Have you ever travelled to Israel to attend ceremonies or participated in international conferences in other places?

5 – Are you prepared to recant your membership in the perverse Baha’i sect?

6 – In accordance with the laws of the Islamic Revolutionary Court of Justice, I hereby undertake to be responsible for the consequences, should it transpire that the aforesaid is false.

Provide in writing the value of your assets and those of your immediate family members.

Provide in writing your full address and telephone number.