Refugee Status Determination Application Form (copy)

Education

Name of institution

Country

From

Qualification obtained

Occupation

Name of employer

Job title

Country

From

Reason of employment recession

Close family members living in Israel

Full name

Passport number

Nationality

Date of birth

Sex

Male

Female

Relationship to applicant

Occupation

Dependants and other accompanying family members living in Israel

Full name

Passport number

Nationality

Date of birth

Sex

Male

Female

Relationship to applicant

Occupation

Family members in home country or in other countries

Full name

Passport number

Nationality

Date of birth

Sex

Male

Female

Relationship to applicant

Current country of residence

Address

Telephone

Occupation

Last address in country of origin

Full address of last place of residence in home country

RSD Application History

Previous Applications for refugee status/asylum in other countries

Country of application

Registration number

Date of registration

Decision/Status obtained

Travel Details

Date of departure from home country

Means of travel out of home country

Exit point from home country

Did you experience any problem leaving your country

please provide detailed explanation

Countries of transit

Country of Transit

From

Travel Document Used

Entry to host country-Israel

Entry point in Host Country-Israel

Date of arrival in Israel

Have you been to Israel before

please provide dates and the reason of visit

Have you entered Israel before with a travel document carrying personal details other than in your last travel document

please provide travel document's number, issuing country, dates and the reason of visit

Have you been to countries other than Israel during the last 5 years

please provide dates and the reason of visit

Documents obtained illegally

When answering the questions below, please provide all the information to why you believe that you are in need of refugee status. You should provide as much details as possible, including the dates when the relevant events occurred. It is important that you provide full and truthful answers to these questions.

Why did you leave your home country?

When did the circumstances which made you leave your country begin?

Have you been arrested or detained in your country?

Is there a specific person or organisation who you assume may harm you in your country?

Were you an active member or supporter of any political party or other organisation ?

Were any of your family members politically active or involved in other organisation ?

Did you experience any problems regarding your religion?

Did you experience any problems regarding your race or ethnicity?

Did you experience any problems regarding your nationality?

Did you turn to your country's authorities for protection?

Did you try to move to another place in your country?

Have you served in the army or in other security forces?

Were your in a need of medical treatment due to the problems in your country?

What do you believe may happen to you, or to your family, if you return to your country?

Are there any additional reasons that may prevent you from returning to your country?

Attached documents

Document type

Document number

Place of issue

Date of issue

Date of expiry

Original possessed

Yes

Missing documents

Declaration

* I declare that the information I have provided on and with this form is complete, correct and current in every detail

* I understand that if I have given false or misleading information, my application for refugee status may be refused, or if I have been granted refugee status that status may be revoked.

* I undertake to inform the Population and Immigration Authority of any significant change in my situation while my application is being considered, including any change in my address, Email and phone numbers, the arrival or departure of members of my household or other changes in my family situation

The answering on one of the following questions is required

I declare that the Refugee Status Determination Application Form was filled by myself without any other person's assistance.

I was assisted by another person in filling of the Refugee Status Determination Application Form and his details are as follows:

First name of the assistant

Last name of the assistant

Contact Number of the assistant