[PROVISIONAL TRANSLATION FROM PERSIAN]
[Translator’s notes appear in square brackets]
[Personal information has been redacted.]
[A questionnaire from Mina Glassmaking Company to identify the Baha’i workers and their willingness to recant their belief]
Mina Glassmaking Company
I, Name: ------, Family name: -----, Father’s name: ----- Birth Certificate number: -----, Place of issue of Birth Certificate: -----, Baha’i Registration number: -------, am⎕/ am not⎕ a member of the Perverse Sect of Baha’ism and in the future, through advice and guidance [given to me], will find the path leading to the truth and will ⎕/will not⎕ stop following this sect.