[PROVISIONAL TRANSLATION FROM PERSIAN]

 

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

 

[Questionnaire]

 

Please complete the inquiry form below and be assured that the content of this sheet will always remain confidential.

[Place to enclose photo]

 

  1. Name –------ Mention your other name if you have one ----
  2. Family name ----- Nickname ---- Mention your other last name if you had one in the past ----
  3. Name and family name of father -------
  4. Name of mother ------
  5. Date of birth or age and place of birth --------
  6. Birth certificate number and place of issue ------
  7. Specific signs -----
  8. Occupation and position ------
  9. Residential address and phone number --------
  10. Do you own your residential house or [do you] rent (if renting the amount of rent) -----
  11. Religion ---- citizenship/allegiance ----
  12. Level of education -----
  13. Military service was completed on what date ---- in which position ---- in which part --- and which place ----.
  14. Are you married or not -----
  15. Your wife is from which family (if foreigner her citizenship and her complete information )
  16. Number of children (male or female) with their names -------
  17. Occupation of each of the children -----
  18. Immediate family including blood relatives and non-blood relatives

 

Place for signature -----

N/323-39

 

  1. With which of the famous families are you close?
  2. Your close friends and companions -----
  3. Your health status
  4. The amount of your wealth including goods and properties?
  5. In which part of the country do you have properties?
  6. Which languages are you familiar with?
  7. Name your written books, articles or magazines ------
  8. What are your artistic and scientific works?
  9. What kind of books, magazines or newspaper are you interested in -----
  10. How do you spend your spare time ----
  11. What are your interests?
  12. How much influence do you have on people, relatives or populations ---
  13. Provide a summary of the history of your services and occupations -----

 

Place for signature
N/323-39

 

 

  1. Assets
  2. Have you ever been arrested by police officers?  In case of being arrested, the date and place of arrest ----, reason ----did it lead to a conviction? In case of a conviction, mention the length of that ----
  3. Mention the travels that you have done with their date – length – reason – place – stopover – companions
  4. Mention any history of political activities such as participation in [political] parties, populations, communities, unions, syndicates, clubs, and associations. Mention the date and place of those activities
  5. In which of the parties, populations, communities, unions, syndicates, clubs, and associations do you currently have a membership?
  6. Other information that may introduce you better

 

 

Place for signature ----

N/323-39