[Translator’s notes appear in square brackets]

[Personal information has been redacted.]



In the Name of God

Mina Glass Manufacturing

Joint Stock Company



The dear colleagues are required to provide accurate answers to the following:

Name.....Surname.....Father’s name.....Identification Number.....Born on.....


Phone Number (for emergency contact)

Military service status:

Expired, year -----

Medical exemption -----

Custody exemption -----

Follower of Religion: Shia/Baha’i sect ----- (clarify if you are a follower of other official religions)

In the case of being a Baha’i:  Baha’i registration number ----- and place of registration ----- to be specified.

Prior to employment at this company, where have you worked?

If you were terminated from employment or resigned, indicate the reason.

Were you active during the Shah’s regime [i.e., were you a supporter of the Shah’s regime]?

Date on which this form was completed -----

In case you are illiterate, the name of the person who completed this form on your behalf is required.


[Contact details]


Mina Glass Manufacturing

Name ----- Father’s name ----- Identification Number ----- Issued at ----- Baha’i registration number ----- I am ----- am not -----   a follower of the Baha’i sect, and in the future I will be guided to the right path and renounce this sect ----- do not renounce this sect -----