Section I

(TO BE COMPLETED BY PERSON FILLING OUT THIS REGISTRATION CARD)

Name*:

Address:

City, State:

ZIP code:

Country*:

Home Phone Number:

Cell Phone Number:

Email Address:

If you are filling this out for someone else, what is your relationship to them:

Section II

Family Name:

First Name:

Maiden Name or Other:

Section III

Name of Village, Town or City in Iraq:

Occupation:

Year of Departure:

Where did person go after leaving Iraq?

How long did they stay there?

Where did they finally resettle?

Please list any assets confiscated or abandoned in Iraq.

Family Assets (homes, business, property, bank accounts, pensions, etc.):

Communal Assets (synagogues, schools, cemeteries, mikvas, etc.)

Can you describe how your property was confiscated?:

Would you be willing to be interviewed about your family history/experience?
 Yes No

Are you willing to assert your story publicly?  Yes No