Convicted of a crime or offense | No __ | Yes __ | To be approved |
Sentenced to serve a period of time in jail or in other form of detention | No __ | Yes __ | you are required |
Placed on probation | No __ | Yes __ | to be of good |
Charged pending trial | No __ | Yes __ | character. |
Nature of Court | __________________________ | Country | ______________________________ |
Date of sentencing DAY / MONTH / YEAR |
Sentence | __________________________________________________________ | ____ / ____ / ______ |
Nature of Court | __________________________ | Country | ______________________________ |
Date of sentencing DAY / MONTH / YEAR |
Sentence | __________________________________________________________ | ____ / ____ / ______ |
25. Have you ever served in the armed forces? | No __ | Yes __ |
Nationality | ______________________________________________ | Date of Discharge | Rank |
Service | ______________________________________________ |
DAY / MONTH / YEAR ____ / ____ / ______ |
__________ |
Type of Discharge | ___________________________________________________________________ |
Training or Specialty |
___________________________________________________________________ |
Deported, excluded or removed from any country? | No __ | Yes __ |
Asked to leave a country? | No __ | Yes __ |
Refused entry to any country? | No __ | Yes __ |
Refused a visa (including a visa to migrate to any country)? | No __ | Yes __ |
I declare that the information supplied on this form, and any attachments, is complete, correct and uptodate in every detail. I understand that if I have given false or misleading information, my application may be refused. I undertake to inform the New Utopian Government Office of any material changes to my circumstances while my application is being considered. I declare that I have read and understood the information supplied to me and in particular the information contained in the Explanatory Notes to this application. By signing below or otherwise permitting my nomination for citizenship, I agree to be subject to the provisions of the Constitution of the Principality of New Utopia and to abide by the laws duly passed in accordance with it. |
Date | |
______________________________________________________________ | DAY / MONTH / YEAR ____ / ____ / ______ |