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Н ОТЕ: FORM A for use by surviving victims of Nazi persecution W hen f i l l a d - i n t h i s T he Under* S e c r e t a r y f o r m s h o u l d b e s e n t t o o f S t a t e, T h e F o r e i g n O f f l o LONDON S. W. l. APPLICATION FOR REGISTRATION AS A BRITISH VICTIM OF NAZI PERSECUTION N.B. 1. Before completing this form it is important to read carefully the attached Notes for Guidance and then to answer all questions fully. 2. Please attach all documentary evidence to the form. All documents sent will be returned. 3. All applications must be received before the 31st of July, 1965. 4. Acceptance of an application for registration does not constitute a right to participate in the distribution. SECTION ONE IDENTITY Surname...3 Q.M Ж Q fi. i Zr.E-... Other names.. c L A &. n.t :... w ji m e q... Address... L y. K W.0.0.. d... 1 Г... f i l M i... J.ALTÂ <... W a < ) d...q u e KM t t y.... L H.A M Ш.1 L S À Æ M P f S... SECTION TWO NATIONALITY 1. How did you acquire British nationality? (Please write YES opposite the method that applies and delete the others) (a) By birth?.^..s... (If so, please attach birth certificate) (b) By marriage?...(if so, please attach marriage certificate and birth or naturalisation certificate of husband) (c) By naturalisation?...(if so, please attach certificate) (d ) By some other method?...(if so, please give full details) 2. If you are not British by birth what was your previous nationality? Do you still retain that nationality?... If not, when and how did you lose it?... (Please attach all documentary evidence) 20048 2 4618 2 (2)
3. If you are a dual-national (a) Where were you ordinarily resident on the 9th of June, 1964?. 2 (Please attach all available evidence, e.g., receipts for rent or rates, &c.) (b) Have you been in Crown Service under Her Majesty s Government in the United Kingdom? (If so, please give full details and dates) N o (c) Are you the holder of a British passport? (If so, please give number and full details) Mo SECTION THREE PERSECUTION 1. Please give, on a separate sheet, the following details of your imprisonment: (a) Name of camp or other place of detention, its situation, its general conditions and régime; (b) Dates of imprisonment and of release; prison number; reasons for imprisonment and circumstances in which it arose; (c) If you are suffering permanent disability as a result of treatment received during your imprisonment please give full details of its nature and cause; (d ) Any other information you consider useful and relevant. (Please attach all documentary evidence) 2. Have you at any time received any payment in respect of this persecution?......m.o... (If YES please give full details) I hereby declare that all the above statements are to the best of my knowledge and recollection true in all particulars. Signature. Date. - iv. 1 ij.. i/i/uc