SCHEDULE 5 REGULATION 7 Application for Certificate of Naturalisation by an Alien or British Protected person. N.B. Portions of this form which are not applicable must be struck out and initialed in every case. CAUTION: To give false information on this form, purposely or recklessly is a criminal offence punishable with imprisonment, (Section 14 Grenada Citizenship Act, 1976). 1. (a) Original name in full in country of birth (Block Letters) If name at birth has been altered, give particulars and date of alteration (c) Particulars of any other name(s) used for trading or business purposes (d) Particulars of any other name(s) used for trading or business purposes (e) (f) (g) Private Occupation Business (h) Name and address of employer(s) Name Name Name (i) If a company Director, name(s) and Name address(es) of company(ies) concerned 2. (a) Country, and date of birth Country of Birth (c) Name of Protectorate, protected state or trust territory from which you derive the status of a British Protected Person Say how you acquired that status
(d) Particulars of any other national status 3. (a) Father s full name in country of his birth (Block Letters) (c) Present address (if living) OR Nationality, if dead (at the time of death) Mother s full name before marriage in country of her birth (Block Letters) (d) Present address (if living) OR Nationality, if dead (at the time of death) 4. (a) State whether single, married, widower, widow or divorced If married, state and place of marriage (c) Give details of applicants husband Full name at Birth (Block Letters) of Birth of Birth Nationality Present if living (d) If husband or wife is dead, give date (e) If marriage dissolved give date and 5. STATEMENT REGARDING RESIDENCE OR SERVICE UNDER THE GOVERNMENT OF GRENADA (a) RESIDENCE : During the period of seven years immediately preceeding the date of this application I have lived in Grenada as follows : Full details of residence in Grenada (State in full each From To Years Months address at which you have resided) (s)
Total residence in Grenada Years Months During the period of residence shown above, I have visited the following Name of Country From To (s) Countries SERVICE UNDER THE GOVERNMENT OF GRENADA : During the period of seven years immediately proceeding the date of this application I have been in Service as follows: Details of Service Government Department By which employed Capacity in Which employed From (s) To Total length of Service 6. STATEMENT OF FUTURE INTENTIONS If this application is granted, I intend to live in (Years) (Months) or to enter into or continue in service under the Government in the capacity of 7. COURT PROCEEDINGS (a) Details of all criminal proceedings taken against you, whether in Grenada or any other country, which resulted in a conviction : Nature of Charge Result _ Details of all non criminal proceedings taken against you in Grenada : Nature of Proceedings Result _
8. (a) Are you financially solvent? Answer Yes or No of any composition (c) of Bankruptcy (d) of discharge Made with creditors from Bankruptcy 9. Approximate date of any previous application for Naturalisation 10. Particulars of children (a) Full names of children of of Current Under 18 years of age Birth Birth Resident to be registered Full names of other of of Where now children Birth Birth Resident I, the undersigned to whom the foregoing particulars relate hereby apply to the Minister for the grant of a Certificate of Naturalisation (and for the registration of my minor children indicated in section 10 (a) above). I, do solemnly and sincerely declare that the foregoing particulars stated in this application are true, and I made this solemn declaration conscientiously believing the same to be true. If, at any time before a Certificate is issued to me, the accuracy of any of the foregoing, particulars is affected by an alteration in circumstances I undertake to inform the Minister in writing forth. (Applicant s ) of Application Made and subscribed this day of, 20 Before me at ( of Justice of the Peace, Notary Public or other Official) 1. Name (Block Letters) Mr. Full Postal REFERENCES
I, the undersigned hereby state that I am a citizen of Grenada and a British subject, by birth; that I am a householder, and 2. Name (Block Letters) Mr. Full Postal I, the undersigned hereby state that I am a citizen of Grenada and a British subject, by birth; that I am a householder, and 3. Name (Block Letters) Mr. Full Postal I, the undersigned hereby state that I am a citizen of Grenada and a British subject, by birth; that I am a householder, and 4. Name (Block Letters) Mr. Full Postal I, the undersigned hereby state that I am a citizen of Grenada and a British subject, by birth; that I am a householder, and
FOR OFFICIAL USE ONLY PLEASE DO NOT WRITE IN THIS SPACE Amount of Fees Paid: $ Certificate Issued: Examining/Issuing Officer(s) :