Word Format - the embassy of nigeria in the hague_ the netherlands

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					                               EMBASSY OF NIGERIA
                         Wagenaarweg 5, 2597 LL, The Hague
                         Tel. 070 3501703 / Fax. 070 355 1110

                        APPLICATION FORMi FOR
                  RENUNCIATION OF NIGERIAN CITIZENSHIP

1.    PARTICULARS OF APPLICANTS (In Block Letters)

i. Surname …………………………….. Other Names ………………………………………
             (Mr./Mrs./Miss/Dr.)

ii. Place of Birth ……………………………………………………..
                                                                    RECENT
iii. Date Of Birth.……………….…………………………………….                          PASSPORT
                                                                 PHOTOGRAPHS
iv. State of Origin…………………..………………………………..                           TO BE
                                                                ATTACHED HERE
v. Local Govt. Area……………….…………………………………
vi. Home Town / Village:.…………………………………………….………………………..
vii. Home Town Address…………………….…….……………………………………………
.…………………….………………………………………………………………………………
viii. Address Before Leaving Nigeria……………………………………………………………
…………………………………………………………………………………………………….
ix. Passport Number…………………………... x. Date of Issue………………………………
xi. Place of Issue…………………………………. xii. Validity…………………………………
xiii. Height …………(in meters)
xiv. Visible Identification Mark ……………………………………………………………….
xv. Date of Arrival in Netherlands………………………………………………….…………..
xvi. Address in Netherlands………………………….………………………………………….
………………………………………………………………………………………………………
2. MARITAL STATUS         Single     Married     Divorced       Living-together
If Married:
i. Name of Spouse…………. …………………………. ii. Nationality………………………..
iii. Permanent Home Address…………………………………………………………………..


iv. Names of Children (if any) (a) …………………………………………………...…………
                               (b)………………………………………………………………
                                                                                  1
                                      (c)…………………………………………………………….
                                      (d)…………………………………………………………….
                                      (e)………………………………………………………………
                                      (f)……………………………………………………………..
3.      PARTICULARS OF RELATIVES.
a.      Father
i. Surname ……………………………… Other Names………………………………………
ii. Date of Birth ………………………… iii. Place of Birth .........................................................
iv. Address………………………………………………………………………………………...
………………………………………………………………………………………………………
b.      Mother
i. Surname: ………………………………… Other Names: …………………………………
ii. Maiden Name: …………………………….. iii. Date of Birth: ……………………………
iv. Place of Birth:………………………………………………………………………………..
v. Address:……………………………………………………………………………………….
………………………………………………………………………………………………………
c.      Most Senior Brother
i. Surname:………………………………… ii. Other Names ………………………………….
iii. Date of Birth:…………………………………. iv. Place of Birth:…………………………..
v. Address:……………………………………………………………………………………….
……………………………………………………………………………………………………
d.      Most Senior Sister
i. Surname:…………………………… Other Names:…………………………………………
ii. Maiden Name (if Any) ……………………………………
iii. Date of Birth:…………………………… iv. Place of Birth ………………………………..
v. Address:……………………………………………………………………………………..
…………………………………………………………………………………………………..
e. Others
i. Surname:……………………………………… Other names:………………………………
ii. Date of Birth:…………………………………… iii. Place of Birth:………………………..
iv. Address:………………………………………………………………………………………
……………………………………………………………………………………………………




                                                                                                             2
4.     EDUCATION:
a.     Primary School
i. Name of School:…………………………………………………………………………………
ii. Address of School:……………………………………………………………………………..
…………………………………………………………………………………………………….
iii. Certificate Obtained:…………………………………………………………………………
b.     Secondary School
i. Name of School:………………………………………………………………………………..
ii. Address of School: ……………………………………………………………………………
…………………………………………………………………………………………………….
iii. Certificate Obtained:…………………………………………………………………………
c.     Tertiary Institution Attended
i. Name of School:…………………………………………………………………………………
ii. Address of School:……………………………………………………………………………
iii. Certificate Obtained:…………………………………………………………………………
5.     LEGAL OBLIGATIONS
State briefly any legal obligations to the following, if any:
a. Student Loan Board:……………………………………………………………………………
……………………………………………………………………………………………………..
…………………………………………………………………………………………………….
b. The Army/Other Security Agencies:………………………………………………………
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
c. Banks/Other Financial Institutions:…………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
d. Federal /State Government:…………………………………………………………………
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
e. Private Individuals:……………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………




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f.        Have You Ever Been Convicted In A Court Of Law In Nigeria?                          Yes        No
If Yes:
i. State Purpose of Conviction:………………………………………………………………
ii. Penalty:………………………………………………………………………………………
6.        NATIONALITY
i. New Nationality:…………………………… ii. Date Granted:……………………………
iii. Passport Number:………………………….. iv. Date of Issue:…………………………


7.        I certify that the information given above are correct and that consent to this
application should be based on its authenticity.

Signature                                                                     Date

…………………………………………………..                                                         ………………………………



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OFFICIAL USE:

Name of Consular Officer: …………………………………………………………………

Signature:                         …………………………………………………………………

Date:                              …………………………………………………………………

General Comments:.………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….

i
 Note: This application will not be processed if this form is not fully and carefully completed in duplicate.
The Embassy will not take any responsibility for your delay in returning this form.




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posted:2/5/2010
language:Dutch
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