What is your name?

What is your e-mail address?

Phone number?

What is your postal address?

What country are you normally based in? Aotearoa Papua New Guinea Fiji United States Sweden Germany Ecuador Australia Saudi Arabia Kemp Land Serbia Tibet Samoa Antarctic Confederation Cook Islands Tuvalu Russian Federation Tonga Philippines Upper Yafa Malaysia East Timor Niue Port Maria Moluccas India Tokelau Islands Maldive Islands Yemen Free Vinland Egypt Bosnia Brazil Waiheke Island Denmark Brunei Albania United Arab Emirates Guatemala Occussi-Ambeno Egypt Greece Sedang Italy Great Barrier Island Switzerland Liegerland Chile Panama Montenegro Hawaii other

What country are you located in now? Aotearoa Papua New Guinea Fiji United States Sweden Germany Ecuador Australia Saudi Arabia Kemp Land Serbia Tibet Samoa Antarctic Confederation Cook Islands Tuvalu Russian Federation Tonga Philippines Upper Yafa Malaysia East Timor Niue Port Maria Moluccas India Tokelau Islands Maldive Islands Yemen Free Vinland Egypt Bosnia Brazil Waiheke Island Denmark Brunei Albania United Arab Emirates Guatemala Occussi-Ambeno Egypt Greece Sedang Italy Great Barrier Island Switzerland Liegerland Chile Panama Montenegro Hawaii other

Preferred place to re-settle? Aotearoa Papua New Guinea Fiji United States Sweden Germany Ecuador Australia Saudi Arabia Kemp Land Serbia Tibet Samoa Antarctic Confederation Cook Islands Tuvalu Russian Federation Tonga Philippines Upper Yafa Malaysia East Timor Niue Port Maria Moluccas India Tokelau Islands Maldive Islands Yemen Free Vinland Egypt Bosnia Brazil Waiheke Island Denmark Brunei Albania United Arab Emirates Guatemala Occussi-Ambeno Egypt Greece Sedang Italy Great Barrier Island Switzerland Liegerland Chile Panama Montenegro Hawaii other

How long have you been a refugee? Family with you? None 1 2 3 4 5 6 7 more than 7 Any Children? None 1 2 3 4 5 6 7 more than 7

Type of situation that caused you to become a refugee? Please select best option War or civil unrest Earthquake Ethnic strife in my home country Political differences with rulers of my homeland Famine Family strife about my marriage plans Family strife over other matters Corporate victimisation Discrimination against me on account of my ethnic origin Discrimination against me on account of my sexual preference Discrimination against my family on account of my political views Discrimination against my family on account of my sexual preference other

What is your ethnic origin? Swedish Occussian Asian African Arabic Latin American Turkish Indian Albanian English United States of America Maori Aboriginal Bantu Pigmy Tibetan Cook Islander Melanesian Polynesian French Japanese German Dutch Russian Native American other

Religious affiliation? Political affiliation?

I am (usual occupation) Student Wage worker Bank employee Housewife Photographer Retired Unemployed Artist Musician Dialectician Sickness beneficiary Computer technician Retail salesperson Mechanic Builder Printer Librarian Manager Other I am (age) 18 - 21 22-25 26-30 31-40 13-17 12 or under 41-50 51-60 61-70 71-80 81 or over I am (sex) Female Male other

Best time to ring me about this registration Before 8 a.m. weekdays 9 a.m. till noon, weekdays Early afternoon, weekdays Late afternoon, weekdays Early evening, weekdays morning, Saturdays afternoon, Saturdays evening, Saturdays morning, Sundays afternoon, Sundays evening, Sundays