INSTRUCTIONS
Please answer each question clearly and completely. Type or print in ink. Read carefully and follow all directions	IRAN-UNITED STATES CLAIMS TRIBUNAL
The Hague, Netherlands
PERSONAL HISTORY FORM+	PLEASE SUPPLY
TWO PASSPORT
PHOTOGRAPHS	
1.  Family name*	First name	Other names	Maiden name	
2.  Date of birth	3. Place of birth	4. Nationality at birth	5. Present nationality	6.  Sex	
7.  Are you aware of any circumstances that may give rise to justifiable doubts as to your impartiality or independence with regard to litigation of claims as between Iran and the United States?  If so, please explain.
	
8. Permanent address	9. Present address	10. Permanent telephone no.	
		11. Present telephone no.	
12.  Have you any dependents?	
Yes ‬	No‬	If the answer is “yes”, give the following information:	
NAME	Age	Relationship	NAME	Age	Relationship	

						
13. Have you taken up legal permanent residence status in any country other than that of your nationality?
If answer is “yes” which country?	YES ‬	NO ‬	
14.  Have you taken any legal steps towards changing your present nationality?
If answer is “yes”, explain fully:	YES ‬	NO ‬	
15. Do you, or any of your close relatives work for, or have any close connection with, any company or government authority in Iran or the U.S.?	
NAME	Relationship	Company/Government authority.	
			
16.  What is your preferred field of work?	
17. Would you accept employment for less than  six months?	18.  If offered an appointment, when could you report for duty?	
YES ‬	No ‬		
19.  KNOWLEDGE OF LANGUAGES.  What is your mother tongue?	
	READ	WRITE	SPEAK	UNDERSTAND	
OTHER LANGUAGES	Easily	Not easily	Easily	Not easily	Fluently	Not fluently	Easily	Not easily	

									
20. For clerical grades only.  Indicate speed in words per minute	List any office machines or equipment you can use	
		Other languages		
	English	French	Farsi			
Typing						
Shorthand						

21.  EDUCATION.  Give full details 	N.B. Please give exact name of institution and titles of degrees in original language. Please do not translate or equate to other degrees	
A.  University or equivalent		
Name, place and country	Years attended	Degrees and academic distinctions	Main course of study	
	from	to			

					
B.  Schools or other formal training or education from age 14 (e.g., high school, technical school or apprenticeship)	
Name, place and country	Type	Years attended	Certificates or diplomas obtained	
		from	to		

						
22. List professional societies and activities in civic, public or international affairs	
	
23.  List any significant publications you have written (Do not attach)	
	
24.  EMPLOYMENT RECORD: Starting with your present post, list in reverse order every employment you have had.  Use a separate block for each post.  Include also service in the armed forces and note any period during which you were not gainfully employed. If you need more space, attach additional pages of the same size.	
From	To	Salaries per annum	Exact title of your post:	
Month/Year	Month/Year	Starting	Final		
Name of employer:	Type of business:	
Address of employer:	Name of supervisor:	
	Number and kind of employees supervised by you:	Reason for leaving:	
DESCRIPTION OF YOUR DUTIES	

From	To	Salaries per annum	Exact title of your post:	
Month/Year	Month/Year	Starting	Final		
Name of employer:	Type of business:	
Address of employer:	Name of supervisor:	
	Number and kind of employees supervised by you:	Reason for leaving:	
			
DESCRIPTION OF YOUR DUTIES	
	
From	To	Salaries per annum	Exact title of your post:	
Month/Year	Month/Year	Starting	Final		
Name of employer:	Type of business:	
Address of employer:	Name of supervisor:	
	Number and kind of employees supervised by you:	Reason for leaving:	
			
DESCRIPTION OF YOUR DUTIES	
	
From	To	Salaries per annum	Exact title of your post:	
Month/Year	Month/Year	Starting	Final		
Name of employer:	Type of business:	
Address of employer:	Name of supervisor:	
	Number and kind of employees supervised by you:	Reason for leaving:	
			
DESCRIPTION OF YOUR DUTIES	
	
From	To	Salaries per annum	Exact title of your post:	
Month/Year	Month/Year	Starting	Final		
Name of employer:	Type of business:	
Address of employer:	Name of supervisor:	
	Number and kind of employees supervised by you:	Reason for leaving:	
			
DESCRIPTION OF YOUR DUTIES	

25.  Have you any objections to our making inquiries of your present employer?	YES ‬	NO ‬	
26.  Are you now, or have you ever been, a permanent civil servant in your government's employ?        	YES ‬	NO ‬	
If answer is “yes”, when?	
27. REFERENCES:  List three persons, not related to you, who are familiar with your character and qualifications.	
FULL NAME	FULL ADDRESS	BUSINESS OR OCCUPATION	
1.			
2.			
3.			
28.  State any other relevant facts.  Include information regarding any residence outside the country of your nationality.	
28.a.  Have you visited Iran or the United States? If so, please indicate date, duration and purpose of such visit/s:	
29.  Have you ever been arrested, indicted, or summoned into court as a defendant in a criminal proceeding. or convicted, fined or imprisoned for the violation of any law (excluding minor traffic violations)?	
	YES ‬	NO ‬	
If “yes”, give full particulars of each case in an attached statement.	
30.  I certify that the statements made by me in this form are true, complete, and correct, to the best of my knowledge and belief.  I understand that any misrepresentation or material omission herein, or in any document I produce to the Tribunal, renders me liable to dismissal.	
DATE:	SIGNATURE:	
N.B. Please do not send any documentary evidence in support of the statements you have made unless and until asked to do so.  In that event, send only copies, not the originals.	
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