Renunciation Form

EMBASSY OF NIGERIA

Wagenaarweg 5, 2597 LL, The Hague

Tel. 070 3501703 / Fax. 070 355 1110

 

APPLICATION FORM[i] FOR

RENUNCIATION OF NIGERIAN CITIZENSHIP

 

1.         PARTICULARS OF APPLICANTS (In Block Letters)

 

  1. Surname …………………………….. Other Names ………………………………………
 

 

RECENT PASSPORT PHOTOGRAPHS TO BE ATTACHED HERE

(Mr./Mrs./Miss/Dr.)

 

  1. Place of Birth ……………………………………………………..

 

iii. Date Of Birth.……………….…………………………………….

 

  1. State of Origin…………………..………………………………..
  2. Local Govt. Area……………….…………………………………
  3. Home Town / Village:.…………………………………………….………………………..

vii. Home Town Address…………………….…….…………………………………………… .…………………….………………………………………………………………………………

viii. Address Before Leaving Nigeria……………………………………………………………  …………………………………………………………………………………………………….

  1. Passport Number…………………………… x. Date of Issue………………………………
  2. Place of Issue…………………………………. xii. Validity…………………………………

xiii. Height …………(in meters)

xiv. Visible Identification Mark ……………………………………………………………….

  1. Date of Arrival in Netherlands………………………………………………….…………..

xvi. Address in Netherlands………………………….………………………………………….             ………………………………………………………………………………………………………

2.  MARITAL STATUS            Single            Married       Divorced          Living-together

If Married:

  1. Name of Spouse…………. …………………………. ii. Nationality………………………..

iii. Permanent Home Address…………………………………………………………………..

 

  1. Names of Children (if any) (a) ………………………………………………………………

(b)………………………………………………………………

(c)…………………………………………………………….

(d)…………………………………………………………….

(e)………………………………………………………………

(f)……………………………………………………………..

  1. PARTICULARS OF RELATIVES.

a.         Father

  1. Surname ……………………………… Other Names………………………………………
  2. Date of Birth ………………………… iii. Place of Birth …………………………………………………
  3. Address…………………………………………………………………………………………

………………………………………………………………………………………………………

b.         Mother

  1. Surname: ………………………………… Other Names: …………………………………
  2. Maiden Name: …………………………….. iii. Date of Birth: ……………………………
  3. Place of Birth:………………………………………………………………………………..
  4. Address:……………………………………………………………………………………….

………………………………………………………………………………………………………

  1. Most Senior Brother
  2. Surname:………………………………… ii. Other Names ………………………………….

iii. Date of Birth:…………………………………. iv. Place of Birth:…………………………..

  1. Address:……………………………………………………………………………………….

……………………………………………………………………………………………………

  1. Most Senior Sister
  2. Surname:…………………………… Other Names:…………………………………………
  3. Maiden Name (if Any) ……………………………………

iii. Date of Birth:…………………………… iv. Place of Birth ………………………………..

  1. Address:……………………………………………………………………………………..

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

  1. Others
  2. Surname:……………………………………… Other names:………………………………
  3. Date of Birth:…………………………………… iii. Place of Birth:………………………..
  4. Address:………………………………………………………………………………………

……………………………………………………………………………………………………

 

 

  1. EDUCATION:
  2. Primary School
  3. Name of School:…………………………………………………………………………………
  4. Address of School:……………………………………………………………………………..

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

iii. Certificate Obtained:…………………………………………………………………………

b.         Secondary School

  1. Name of School:………………………………………………………………………………..
  2. Address of School: ……………………………………………………………………………

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

iii. Certificate Obtained:…………………………………………………………………………

c.         Tertiary Institution Attended

  1. Name of School:…………………………………………………………………………………
  2. Address of School:……………………………………………………………………………

iii. Certificate Obtained:…………………………………………………………………………

5.         LEGAL OBLIGATIONS

State briefly any legal obligations to the following, if any:

  1. Student Loan Board:……………………………………………………………………………

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

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

  1. The Army/Other Security Agencies:………………………………………………………

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

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

  1. Banks/Other Financial Institutions:…………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

  1. Federal /State Government:…………………………………………………………………

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

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

  1. Private Individuals:……………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

 

 

  1. Have You Ever Been Convicted In A Court Of Law In Nigeria? Yes         No

If Yes:

  1. State Purpose of Conviction:………………………………………………………………
  2. Penalty:………………………………………………………………………………………

6.         NATIONALITY

  1. New Nationality:…………………………… ii. Date Granted:……………………………

iii. Passport Number:………………………….. iv.  Date of Issue:…………………………

 

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

Signature                                                                                            Date

 

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

 

 

 

 

Thumb Print

 

 

 

 

 

 

 

 

 

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.