...

Termo de Solicitação de Refúgio - INGLÊS

by user

on
Category: Documents
7

views

Report

Comments

Transcript

Termo de Solicitação de Refúgio - INGLÊS
Ministério da Justiça
CONARE - Comitê Nacional para os Refugiados
CONARE RESOLUTION No. 18
ANNEX I
ASYLUM APPLICATION FORM
I – IDENTIFICATION
Full name: _____________________________________________________________
Gender: male ( ) female ( )
Marital Status: __________________________________________________________
Father’s full name: ______________________________________________________
Mother’s full name: ______________________________________________________
Country of origin/Nationality: _______________________________________________
Date of birth: ___________________________________________________________
Occupation in country of origin before coming to Brazil:
______________________________________________________________________
Technical qualifications, University degrees, and/or membership of a professional
association:
______________________________________________________________________
Level of education: ______________________________________________________
1
Ministério da Justiça
CONARE - Comitê Nacional para os Refugiados
Address in country of origin:
______________________________________________________________________
______________________________________________________________________
Current address:
______________________________________________________________________
______________________________________________________________________
E-mail: ________________________________________________________________
Phone number: _________________________________________________________
Do you speak Portuguese? _______________________________________________
Which languages do you speak?
______________________________________________________________________
Which languages do you understand?
______________________________________________________________________
Are you being assisted by an interpreter in filling out this form? ___________________
If you are being assisted by an interpreter, please state:
a) The interpreter’s full name:
______________________________________________________________________
b) The interpreter’s phone number:
______________________________________________________________________
c) The interpreter’s address:
______________________________________________________________________
2
Ministério da Justiça
CONARE - Comitê Nacional para os Refugiados
d) The interpreter’s e-mail address:
______________________________________________________________________
e) The interpreter’s identity document:
______________________________________________________________________
Travel documents or identity documents (please attach photocopies of the documents.
If this is not possible, please explain the reason why at the back of this paper).
Passport number: _______________________________________________________
Identity Card/Document/Ticket number ______________________________________
Other documents: _______________________________________________________
Family members accompanying you to Brazil (spouse, children, parents, others):
NAME OF THE ACCOMPANYING
FAMILY MEMBER
DATE OF
BIRTH
FAMILY TIE
BETWEEN
THE
COMPANION
AND THE
DECLARANT
LEVEL OF
EDUCATION
3
Ministério da Justiça
CONARE - Comitê Nacional para os Refugiados
Family members currently residing in country of origin or in another country (spouse,
children, parents, others)
NAME OF THE FAMILY MEMBER
CURRENTLY RESIDING IN COUNTRY
OF ORIGIN OR IN ANOTHER COUNTRY
DATE OF
BIRTH
FAMILY TIE
BETWEEN
THE FAMILY
MEMBER
AND THE
DECLARANT
LEVEL OF
EDUCATION
II – CIRCUMSTANCES OF APPLICATION
01. City and date of departure from country of origin:
______________________________________________________________________
02. Means of transport: by air ( ) by sea ( ) by road ( )
On which date did you arrive in Brazil?
______________________________________________________________________
4
Ministério da Justiça
CONARE - Comitê Nacional para os Refugiados
03. Have you applied for refugee status in Brazil?
Yes ( ) No ( )
04. Have you received recognition as a refugee?
Yes ( ) No ( )
If you have been recognized as a refugee, please state:
a) The date on which you received recognition:
______________________________________________________________________
b) The country or countries that granted recognition:
______________________________________________________________________
c) Please provide a photocopy of all documents that demonstrate recognition:
05. What would happen to you if you returned to your country of origin today?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Would you fear to suffer some kind of threat to your physical or mental integrity or to
your freedom if you were to return to your country of origin?
Yes ( ) No ( )
06. If you fear to suffer some kind of threat upon returning in your country of origin,
please indicate the reason why:
5
Ministério da Justiça
CONARE - Comitê Nacional para os Refugiados
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
07. Why did you leave your country of origin?
Please give a detailed explanation. Describe any particular event, personal experience,
or measure adopted against you or your family members, which contributed to the
decision to leave your country of origin (if you possess any evidence, please attach it to
this document. If you need additional space, use the back of this page or use additional
pages).
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
6
Ministério da Justiça
CONARE - Comitê Nacional para os Refugiados
I hereby declare that the information and documents I submitted above are true and
correct to the best of my knowledge and belief.
______________________________________________________
Applicant
______________________________________________________
Interpreter
______________________________________________________
Agent
7
Fly UP