ANNEX III.5

STANDARD FORM FOR DETERMINING THE STATE RESPONSIBLE FOR EXAMINING AN APPLICATION FOR ASYLUM (Text adopted by the Council on 20 June 1994)

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Personal particulars of applicant

1. Surname (*).Maiden name.2. Forename(s).3. Does the applicant use/has he /she used other names? Yes NoWhat are/were they?.4. Date of birth.5. Place of birth.District/region.Country.6. Nationality(-ies) (indicate all).(a) current.(b) previous.(c) none/stateless.7. Sex Male Female8. Name of father.9. Name of mother.10. Marital status Single Married Widowed Divorced 11. Address.- current..

- in country of origin.12. Language(s) of origin.(*) In block capitals Personal particulars of family members 13. Spouse:Surname (*), maiden name, forename(s), sex, date of birth, place of residence (If the spouse is seeking asylum, a separate form should be completed) .

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14. Children:Surname (*), forename(s), sex, date of birth, place of birth, place of residence (indicate all children; a separate form should be completed for children over 16 years of age if asylum is sought) (a) .

(b) .

(c) .

(d) .

(e) .

15. Place and date of the application for asylum in the country of residence .

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Previous asylum procedures

16. Has the asylum applicant ever previously applied for asylum or recognition of refugee status in the country of residence or in another country? Yes NoWhen and where?..Was any decision taken on the application? No Not known Yes, refusedWhen was the decision taken?.Identity papers17. National passport Yes No Number. Issued on.By.Valid until.18. Document replacing passport Yes No Number. Issued on.By.Valid until.19. Other document Yes No Number. Issued on.By.Valid until.20. In the absence of documents:

(specify whether they may have contained a valid visa or residence permit and, if so, indicate the issuing authority and date of issue as well as the period of validity) Departed Lost Stolen Without documents

(When, where? .

.) Other reasons (Which? .) .(*) In block capitals

Residence documents/visas21. Does the asylum applicant possess a residence document/visa for the country of residence? Yes NoType Residence permit Entry visa Transit visaIssued on.by.Valid until.22. Does the asylum applicant possess a residence document/visa for another EU Member State? Yes NoWhich State?.Type Residence permit Entry visa Transit visaIssued on.By.Valid until.23. Does the asylum applicant possess a residence document/visa for a non-member country? Yes NoWhich country?.Type Residence permit Entry visa Transit visaIssued on.By.Valid until.Travel route24. Country in which the journey was begun..(country of origin or of provenance).- Route followed from country where journey was begun to point of entry into country in which asylum is requested..- Dates and times of travel.- Crossed border on.- At the authorized crossing point, or.- Avoided border controls (entered illegally) at.- Means of transport used Public transport (what form? .) Own vehicle Other means (how? .)25. Did the asylum applicant enter via another European Union Member State? No

Yes- Which was the first EU Member State entered?.

.- Crossed border at authorized crossing point, or.

.- Avoided border controls at.- When?.Residence in another EU Member State26. Residence in another EU Member State or States after leaving country in which journey was begun (country of origin/provenance) No Yes- In which State or States?.- From - to.- Place/exact address.- Residence was Authorized Unauthorized- Period of validity of residence permit.- Purpose of residence..Residence in third countries (non-members of EU)27. Residence in third country or countries after leaving country in which journey was begun (country of origin/provenance) No Yes- In which third country or countries?.- From - to.- Place/exact address. Hotel/boarding house Private accommodation Camp Other(Where? .)- Residence was Authorized Unauthorized- Period of validity of residence permit..- Purpose of residence..- Was the asylum applicant in danger of being expelled/removed? Yes No- To which country?.- Why?.- Reasons for continuing journey.Particulars of family members living in EU Member States or in third countries28. (a) Is any member of the family recognized in a Member State or in a third country as having refugee status and as being legally resident there? Yes No- Name of family member - State - Address in that State.

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.(b) Do any of those concerned object to the examination of the application for asylum in that Member State or third country? Yes No>END OF GRAPHIC>