First Name:

Last Name:

Nick Name:

Case Number:

Date of Birth: Day: Month: Year:

Gender:

Male
Female

Sexual Orientation:

Gay
Lesbian
Bisexual
Male to Female Transgender
Female to Male Transgender
Male to Female Transsexual
Female to Male Transsexual

City of Birth:

Telephone:

Email Address:

Country of Asylum:

City of Asylum:

Date of Entry:

Date of Apply:

Date of Interview:

Information of Lawyer:

File Status:

Waiting for Registration
Waiting for Interview
Waiting for Result
Waiting for Resettlement process
Rejected
Closed

Please give a brief account of your reason for seeking refugee status:

Have you ever been arrested in Iran?

If your case has been rejected or is pending, please state the reasons:

Signature:

Would you declare the IRanian Queer Railroad as your representative?

With this I declare the information given in this form is all correct.

I forward my permission to IRQR to contact UNHCR or other related organizations

for endorsements or to inquire more information if it was needed regarding my case

and request for affidavits from other foundations or organizations.

Yes
No

 عکس خود را ضمیمه کنید

Please Attach your Picture: