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 | _____________________________________________________________ |
13. Present country of Citizenship | ________________________________________________ |
14. Do you hold any other citizenships? | ________________________________________________ |
No __ | Yes __ | Which countries? | ________________________________________________ |
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) ____ / ____ / ______ |