[Translator’s notes appear in square brackets]

[Personal information has been redacted.]


In the Name of God

Given name and surname: Houman Ahrari, Father’s name: Seyyed Zia, Highest level of father’s education: Ph.D. in Pharmacology

Father’s occupation: -----

Work address: -----

Work phone number: -----

Given name and surname of mother: Manijeh Golshan, Highest level of education: Post Diploma, Mother’s occupation:  Homemaker ---x---, dismissed for being a Baha’i

Work address: -----

Work phone number: -----

Number of brothers: -----

Number of sisters: -----

Nationality Iranian, Citizenship Iran

Religion:  Islam -----, Christian -----, Jewish -----, Zoroastrian -----, Baha’i ---x---

Do mother and father live together:  Yes--- No---; if divorced, with whom do you live ----

With my mother, because my father was martyred for being a Baha’i

Given name and surname of legal guardian: Manijeh Golshan, my mother

Is your income sufficient to cover your expenses: Yes ---x---  No -----

Type of home you live in: Private ---x---  Rental -----

Home address: [redacted]

What problems do you have in the institution? -----

What problems do you have at home? None


The following portion to be filled by the parent/guardian

How is the behaviour of your child at home: Excellent, respectful and mature

Does your child help you [parents] with the chores at home? Very much ---x--- Some ---- No ----

Have you had serious ailments in the past few years? No ---x--- , if so explain

Do you help your child with his/her school work? Yes ---x---   No ----

Please write your opinion about the management of the institution and system of teaching, etc.

I have no opinion.


Manijeh Golshan


6 Azar 1361 [27 November 1982]