[PROVISIONAL TRANSLATION FROM PERSIAN]

 

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

 

[In this bank’s form, before citizenship there is a question about the applicant’s religion.]

 

Date: 13------

 

In the Name of God

 

[Logo]

Post Bank of Iran

 

Personal data of real persons

 

Place to attach photo

 

Branch: -------, Code: ------

Teller: ------,     Code: ------

File number: ------

Client number: -------

 

Name: ------

Surname: ------

Father’s name: -------

National number: -------

Birth certificate number: ------

Birth certificate serial number: ------

Date of birth: ------

Place of birth: -------

Place of issue: -------

Issuer’s domain number: ------

Religion: ------

Nationality/Citizenship: ------

Gender: Male – Female

Marital status: Single –Married

Residency status: Resident- Non-resident

Education level: ------

Occupation: ------

Home address: ------

Postal code: ------

Home phone: ------

Mobile phone: ------

Email: ------

Work address: ------

Work phone: ------

Fax number: ------

Email: ------

Dependent clients:

First order

Name and surname: ------

Client number: ------

Relationship: ------

Level of authorization: ------

Term of representation/Signature authorization: ------

Second order

Name and surname: ------

Client number: ------

Relationship: ------

Level of authorization: ------

Term of representation/Signature authorization: ------

 

Explanations: ------

Client signature: ------

Client stamp: ------

Bank agent: ------

Stamp and signature: -------

Head of branch/section: ------

Stamp and signature