ANNEX 5Supplementary provisions
ANNEX 5 Text of image (Emblem of Sri Lanka) ..............................................................…… ................................................................……….….……... .................................................................… (Place and date) (Designation of requesting authority) Reference: .............................................………………… To ................................................................………………… (Designation of receiving authority) READMISSION APPLICATION pursuant to Article 7 of the Agreement of 4 June 2004 between the European Community and the Democratic Socialist Republic of Sri Lanka on the readmission of persons residing without authorisation A.PERSONAL DETAILS 1. Full name (underline surname): ...........................................................……………………………… 2. Maiden name: ...........................................................……………………………… 3. Date and place of birth: ...........................................................……………………………… Photograph 4. Sex and physical description (height, colour of eyes, distinguishing marks etc.): …………………………………………………………………………………………...................… 5. Fathers and mothers name: .......................................………………………………………………………………...................… 6. Also known as (earlier names, nicknames or pseudonyms): ...........................................................................................................................………...................… 7. Nationality and language: ...........................................................................................................................………....................… 8. Civil status: married single divorced widowed If married: name of spouse...........................................................................................................……… Names and age of children (if any)………………………………………… ………………………………………… ………………………………………… ………………………………………… 9. Names of brothers/sisters and other next of kin: ............................................................................................................................................................… 10. Last address in the requesting State: ............................................................................................................................………....................… 11. Previous address in the requested State: ...............................................................................................................……………….....................… Text of image 12. Names (and periods) of schools attended in the requested State: ............................................................................................................................................................… 13. Profession and names of former employers in the requested State (if any): ............................................................................................................................................................… 14. Names and addresses of doctors/dentists in the requested State: ………………………………………………………………………………………………………… 15. Date and means of leaving the requested State (by air — name of airline, ship etc.): ............................................................................................................................................................… 16. Date and means of entry to the requesting State: ............................................................................................................................................................… B. SPECIAL CIRCUMSTANCES RELATING TO THE TRANSFEREE 1. State of health (e.g. possible reference to special medical care; Latin name of contagious disease): ............................................................................................................................................…………… 2. Indication of particularly dangerous person (e.g. suspected of serious offence; aggressive behaviour): ............................................................................................................................................…………… C. MEANS OF EVIDENCE ATTACHED 1. ............................................................. (Passport No) ...................................................................... (date and place of issue) ............................................................. (issuing authority) ...................................................................... (expiry date) 2. ............................................................. (Identity card No) ......................................................................……………. (date and place of issue) ............................................................. (issuing authority) ...................................................................... (expiry date) 3. ............................................................. (Driving licence No) ...................................................................... (date and place of issue) ............................................................. (issuing authority) ...................................................................... (expiry date) 4. ............................................................. (Other official document No.) ...................................................................... (date and place of issue) ............................................................. (issuing authority) ...................................................................... (expiry date) D. Observations ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ……………………………………………………………………………………………………… (Signature) (Seal/stamp)