PLEASE FILL THIS FORM OUT AND MAIL IT TO THE ADDRESS BELOW:
P.O. BOX 260443 ENCINO, CA. 91426, U.S.A

 

MEMBERSHIP APPLICATION FOR IRANIAN NATIONAL MOVEMENT FOR FREEDOM:

1. NAME
2. LAST NAME
3. DATE OF BIRTH
4. FATHER'S NAME
5. PLACE OF BIRTH
6. COUNTRY OF RESIDENCE
7. ADDRESS
8. PHONE NUMEBER
9. EMAIL/WEBSITE
10. SIGNATURE
11. DATE

NOTE: PLEASE INCLUDE A COPY OF A VALID ID. AND TWO RECENT PASSPORT SIZE PHOTOS.

 

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