[PROVISIONAL TRANSLATION FROM PERSIAN]

 

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

 

[A questionnaire from Mina Glassmaking Company to enable identification of Baha’i workers and to obtain more information about them]

 

[Emblem]

Mina Glass Company

(Public joint-stock)

 

In the Name of God

 

Dear colleagues are obliged to provide answers to all of the following information:

 

Given Name: ------, Surname: -----, Father’s name: ----- Birth certificate number: -----, Date of birth: -----

Address: -----

 

Telephone number: (For emergency contact)

 

Military Service status: Completed year: -----, Medical exemption: , Guardianship exemption:

 

 

Following Shi’a religion: / Baha’i sect: (Please explain if you follow any other officially recognized religions)

 

If a Baha’i, registration number: ------, the place of registration: ---------

Where did you work prior to working for this company?

If you were fired or resigned, provide the reason.

Did you have any active role in Shah’s Regime?

 

Date of completion: -----

 

In case of illiteracy the name of the person who filled this questionnaire must be provided.

 

[Signature]

 

[Company’s address and contact details are provided]