English Translation

6. STATEMENT REGARDING CHARACTER, ETC.

I am of good character and have sufficient knowledge of the English language. I am financially solvent.

7. Details of ALL PROCEEDINGS OF ANY KIND taken against you in any Civil or Criminal Court.

| Nature of proceedings | Date | Place | Result |
|-----------------------|------|-------|--------|
| none                 |      |       |        |

8. Date of any composition made with creditors: none  
Date of bankruptcy: none  
Date of discharge from bankruptcy:

9. Approximate date of any previous application for naturalisation: none

10. Particulars of children

(a) Full name of children under 21 years of age to be registered (see para. 5 of Instructions)

| Date of birth | Place of birth | Where now resident |
|---------------|----------------|--------------------|

(b) Full names of other children

| Date of birth | Place of birth | Where now resident |
|---------------|----------------|--------------------|

11. APPLICATION (This application must be signed in the presence of one of the persons specified in paragraph 6 of the Instructions.)

Delete and initial the words in brackets if inapplicable

I, the undersigned to whom the foregoing particulars relate, hereby apply to the Secretary of State for the grant of a Certificate of Naturalisation (and for the registration of my minor children as indicated in section 10-(a) above).

I do solemnly and sincerely declare that the foregoing particulars stated in this application are true, and I make this solemn declaration conscientiously believing the same to be true.

If, at any time before a certificate is issued to me, the accuracy of any of the foregoing particulars is affected by an alteration in circumstances, I undertake to inform the Secretary of State in writing forthwith.

(Signature of Applicant)

Made and subscribed this ______ day of ______ 1955

before me ______

(State whether Commissioner for Oaths, Justice of the Peace, Notary Public or other authorised person specified in paragraph 6 of the Instructions)

CAUTION.

Subsection (1) of Section 28 of the British Nationality Act, 1948, provides that :

"Any person who for the purpose of procuring anything to be done or not to be done under this Act makes any statement which he knows to be false in a material particular, or recklessly makes any statement which is false in a material particular, shall be liable on summary conviction in the United Kingdom to imprisonment for a term not exceeding three months."

(OVER)