English Translation

23 Seymour Place,
C 27509
A/Dec1.2

DECLARATION FORM

NOTE:- This form must be completed by the applicant and forwarded with the form A/N 42 and the fee in the enclosed envelope to the Finance Officer, Home Office, Whitehall, London, S.W.1.

I hereby declare that, if naturalised as a citizen of the United Kingdom and Colonies, I will not, when in any country of the Commonwealth, seek the diplomatic or consular protection of Czechoslovakia, nor claim the benefit of any allegiance that I may still be deemed to owe to Czechoslovakia under Czechoslovak law.

Signature of Applicant _____________________________ Date _______________

J. Czernin.
3rd January, 1956.

Address ____________________________________________________________

Occupation: Departmental Manager

Place and date of birth: Prague, Czechoslovakia, 9.8.1924

Nationality: Czechoslovak

Marital status: Single

Name of wife/husband (if any) _________________________________________

Initials: ________

Date: ____________