NOMINEE
YOUR PERSONAL DETAILS
1. Family name
(in English)
____________________________________________________________
2. Given name
(in English)
____________________________________________________________
3. Father's name
 
____________________________________________________________
4. Mother's maiden name
 
____________________________________________________________
5. Have you been known by any other names? (including name before marriage or an alias)
No ___ Yes ___ Name before marriage
(if applicable)
__________________________________________________
N.B.: For other names, enclose a note giving the required details.
6. Sex: Male __ Female __
7. Date of Birth (DAY MONTH YEAR)  ____ / ____ / ______ Age ______
8. Place of Birth Town  ______________________________________________________
State or Province  ______________________________________________________
Country  ______________________________________________________
9. Color of eyes _____________________________________________________________
10. Color of hair _____________________________________________________________
11. Height _____________________________________________________________
12. Distinguishing Marks _____________________________________________________________

CITIZENSHIP
13. Present country of Citizenship ________________________________________________
14. Do you hold any other citizenships? ________________________________________________
No __ Yes __ Which countries?  ________________________________________________

PASSPORT
15. Do you have a passport? Passport Number ___________________________________________
No __ Yes __ Give details: 
Place of issue: 
_______________________________________________________
_______________________________________________________
N.B.: If you have more than one passport, enclose a note giving the required details. Date of issue: 

Valid until: 
 (DAY MONTH YEAR) ____ / ____ / ______

 (DAY MONTH YEAR) ____ / ____ / ______