[Translator’s notes appear in square brackets]

[Personal information has been redacted.]


In the name of God

From:  The Security Office of the Management Education Department, Shiraz, Region 1

To:  All the urban and rural education units * Siyakh Darengun [one of the localities in Shiraz] representative

Number: M/1833/17

Date: 30 Azar 1385 [21 December 2006]




With respect, further to the circular letter number M/1067/17 – 15 Mehr 1385 [7 October 2006], the following form is submitted for recording the information of students who belong to religious minorities and the perverse Bahaism sect.  We request that, after completion, it be returned to this office for necessary exploitations. 

[Closing remarks],

Security Office of the Education Department Management, Shiraz, Region 1



Registration form for information of the students of the city of Shiraz, Area 1, Region 1 * Academic year 1385–1386 [2006–2007]

1-Student’s personal information

Name: ----- Last Name:  ----- Father’s name: -----

Date of Birth: ----- Identification Card Number: ----- Place of Issue: -----

Nickname: ----- Type of degree: ----- Name of Training Institute: -----

Class: ----- Branch: -----

Religion:  Christian ----- Jew ----- Zoroaster ----- Perverse Bahaism sect -----


2- Information of family members:

[A table to fill in the name, surname, age, education, profession, and place of work of the father, mother and all the siblings]

If parents are self-employed, provide a detailed explanation.


3- Last year’s place of education: ----- City ----- Area ----- Region

4- Emergency telephone numbers:

Telephone number: ----- Name of the owner of the Telephone: ----- Relationship to you: -----

5-If parents are deceased or divorced, provide the date.

6-If you use [pickup] services

Name of the driver: ----- Number of the [pickup] service:

7-If the parents are employed after retirement provide the exact place of work.

8-Telephone number of the place of work and cellular phone of parents:

9-Home address:

Home Telephone Number: ----- Postal Code ----- Clear map to your house: -----

Name and last name of the manager of the educational institute

Signature of the manager and the stamp of the educational institute


[Handwritten notes, numbers and date at the top of the page]


13 Esfand 1385

[Handwritten note at the top of the page]

Enclosure 1