THE LONDON CENTRAL MOSQUE TRUST &
THE ISLAMIC CULTURAL CENTRE
A Registered Charity.
146 Park Road, London NW8 7RG.
Tel: 020 7724 3363 (10 Lines). Fax: 020 7724 0493
Website: http://www.iccuk.org Email: info@iccuk.org
Islamic Divorce Booking Form
Date Time
Details Husband Wife
Surname (Last Name)
First Name
Date of Birth
Telephone
Address UK
Overseas
UK Resident?
Yes No Yes No
Nationality
Passport Number
Born Muslim? Yes No (Embraced) Yes No (Embraced)
Islamic Marriage Certificate (Nikah) Details
Mosque/Center and Country
Certificate Number
Date of Islamic Marriage
Names of the Two Muslim Male Witnesses
1st Witness 2nd Witness
Which divorce is this?
First Second Third
Official Use Only
Submitted Supporting Documents
Islamic Marriage (Nikah) Certificate Husband’s Passport Wife’s Passport
Processing Fees
Date Amount Cheque No. Receipt No.
Name of ICC Imam Islamic Divorce Certificate No.