Le Greffe

The Registry

Application for permission to visit a detained person1 (Annex 1)

Instructions: Complete this form. Try to be as detailed as possible in describing your relationship to the detained person, for example: Friend is not sufficient information: describe how long you know each other, from where you know each other, when was the last time you met, etc. Family relationships should be described in detail, for example: my mother is a sister of the detained person. Mail, fax or e-mail this completed and signed form together with a legible copy of your passport picture page to: Mail: ICC Att. Detention Centre P.O. Box 19519 2500CM The Hague The Netherlands Fax: +31 70 515 8965 E-mail: detention.visits@icc-cpi.int Telephone: +31 70 515 8080 Please note that: Visits depend upon the availability of facilities; Whenever an electronic application is used, you will be requested to sign your name on a hard copy of the application form upon your arrival at the detention centre; Give at least 15 calendar days between this application and proposed visiting time; Due to unforeseen circumstances, the visit may not be authorised within these 15 calendar days: you are therefore advised not to make any travel arrangements before your visit is approved; This form consists of four pages; Incomplete and/or illegible forms will not be processed;

Detained person you wish to visit Visitor Surname(s) (family name(s)) Surname(s) at birth (earlier family name(s)) First names (given names) Date of birth (day-month-year) Place and country of birth Visitors Fathers name Visitors Mothers name
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In accordance with Regulation 179 of the Regulations of the Registry All visitors other than counsel, diplomatic or consular representatives, representatives of the independent inspecting authority, or officers of the Court, shall first apply to the Registrar for permission to visit a detained person.

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Present address

Permanent Address

Address while in The Netherlands (or of country of stay during the visit)

Telephone numbers: Residential: Mobile: Local number in Europe: Fax number

E-mail address

Nationality Number of passport Issued by

Date of issue Valid until

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State in detail your reason for the visit. Describe in detail your relationship to the detained person.

Name of Employer:

Work Address:

Work Telephone number: Job Title: Employed since: If student, name of university/school and address: Political Role: Have you served in the Political Party of any country? If yes, state the name of the Political Party and your role. Military Role: Have you served in the Armed Forces of any country? If yes, describe the nature of your services. State your position, rank and duration of service. If you were discharged, state the date and reasons for discharge. As a member of the Armed forces, were there any charges or proceedings instituted against you?

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If yes, provide sufficient details of the charges and the final decision in the case.

Criminal Record: Have you ever been arrested for any crime in any country including the country of your birth, nationality, residency or any other? If YES, provide details on the charges against you, the city, state and country and dates of your arrest. Have you ever been found guilty of a crime in any country? If YES, provide details on the charges, the sentence, name and location of the penitentiary and the dates when you served your sentence. Do you have any particular role or status in respect to the ongoing proceedings? Requested visiting date and time: (NB: If unspecified, visits will be scheduled for an hour approximately 20-25 calendar days from the receipt of this form. You may be required to submit a new form to re-schedule visits.) Have you previously visited the detained person? If so, when was the last time? Which languages do you speak?

I confirm that all information I have provided is correct and that the Detention centre may inquire further if it so wishes. I declare that I shall not disclose any information to the media.

Date _______________________

Signature _______________________________ Version 1, English

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