S.I. No. 660/2016 - International Protection Act 2015 (Application for International Protection Form) Regulations 2016.

Notice of the making of this Statutory Instrument was published in

“Iris Oifigiúil” of 6th January, 2017.

I, FRANCES FITZGERALD, Minister for Justice and Equality, in exercise of the powers conferred on me by sections 3 and 15 (5) of the International Protection Act 2015 (No. 66 of 2015), hereby make the following regulations:

1. (1) These Regulations may be cited as the International Protection Act 2015 (Application for International Protection Form) Regulations 2016.

(2) These Regulations shall come into operation on 31 December 2016.

2. The form set out in the Schedule is prescribed for the purposes of section 15 (5) of the International Protection Act 2015 (No. 66 of 2015).

Schedule

International Protection — Application Form

Application for International Protection to the Minister for Justiceand Equality in accordance with Section 15 of the International Protection Act, 2015.

International Protection Office,

Irish Naturalisation and Immigration Service,

79 — 83 Lower Mount Street,

Dublin 2.

I hereby apply for international protection in Ireland in accordance with Section 15 of the International Protection Act, 2015.

NOTE: MORE DETAILED INFORMATION ON THE REASON FOR YOUR APPLICATION MAY BE PROVIDED IN THE INTERNATIONAL PROTECTION QUESTIONNAIRE

(i) FAMILY NAME:
(ii) FORENAME:
(iii) DATE OF BIRTH:
(iv) COUNTRY WHERE BORN:
(v) NATIONALITY:
(vi) IF NO NATIONALITY, COUNTRY OF HABITUAL RESIDENCE:
(vii) ADDRESS IN OWN COUNTRY:
(viii) NAME OF SPOUSE/PARTNER, IF APPLICABLE:(please complete a separate line for each person.)	(ix) DATE OF BIRTH AND CURRENT WHEREABOUTS:

This form must be completed in English

(x) NAMES OF CHILDREN UNDER 18 YEARS OF AGE, IF APPLICABLE:(please complete a separate line for each person, specify their gender and specify exact nature of relationship to applicant for each).	(xi) DATE OF BIRTH AND CURRENT WHEREABOUTS:







(xii) NAMES OF YOUR PARENTS(please complete a separate line for each person)	(xiii) DATE OF BIRTH AND THEIR CURRENT WHERABOUTS

Please provide all the reasons why you are claiming international protection.

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In the event of your protection application being refused please briefly state any other reasons why you and your children under 18 years of age (if any) cannot or should not be returned home to your Country of Origin/Country of former habitual residence and should be permitted to remain in the State. You may submit additional information with your Questionnaire.

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I have completed the contents of this form myself which are correct. I understand that the details I have given here will help form the basis of my application for international protection. I understand this information may also be used, if necessary, when considering other matters under the International Protection Act, 2015 , i.e. Permission to Remain, Refoulement and Family Reunification.

(If applicable).

Signature of Applicant:.............. Date: ..............

The contents of this form which are correct have been read back and interpreted for me. (If applicable).

Signature of Applicant: .............. Date: ..............

Signature of Guardian: .............. Date: ..............

TUSLA — Child and Family Agency official

(If applicable).

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GIVEN under my Official Seal,

22 December 2016.

FRANCES FITZGERALD,

Minister for Justice and Equality.

EXPLANATORY NOTE

(This note is not part of the Instrument and does not purport to be a legal interpretation)

These Regulations prescribe the application form for the purposes of Section 15 of the International Protection Act 2015 .