Asylum Interview Application

ASYLUM INTERVIEW APPLICATION

This Asylum Interview Application is made between Applicant Name: (hereinafter "Applicant") and Receiving Authority Name: (hereinafter "Authority"), submitted on Application Date: for the purpose of requesting an in-person asylum interview and related administrative actions.

RECITALS

WHEREAS, Applicant alleges a well-founded fear of persecution in Applicant's country of origin based upon one or more protected grounds and seeks a full, fair and timely asylum interview with Authority; and

WHEREAS, Authority maintains jurisdiction to schedule and conduct asylum interviews under applicable immigration statutes, regulations and administrative procedures and may require information and declarations necessary to determine eligibility; and

WHEREAS, Applicant submits this application to provide the information required to permit Authority to determine whether an interview should be scheduled and to record Applicant's preferences and supporting documentation.

NOW, THEREFORE, in consideration of the mutual statements and agreements herein, Applicant and Authority agree as follows:

1. APPLICANT IDENTIFICATION

2. BASIS FOR ASYLUM CLAIM

Applicant asserts the asylum claim arises from persecution or a well-founded fear of persecution based on one or more protected grounds. Applicant asserts the following grounds (check all that apply):

Race
Religion
Nationality
Political opinion
Membership in a particular social group

3. SUPPORTING DOCUMENTS

Applicant certifies that the following documents are submitted with or will be provided at the interview (check all that apply):

Passport or travel document
National ID cards or birth certificate
Police reports or medical records
Affidavits or witness statements
Other supporting evidence

4. INTERVIEW SCHEDULING PREFERENCES

Applicant requests an interview with the following preferences and accommodations:

5. REPRESENTATION

If Applicant is represented, provide representative information below. Applicant may substitute or change representation in writing prior to the interview.

6. CONFIDENTIALITY AND PRIVACY

Authority shall treat information submitted in this application as confidential to the extent required by applicable statutes and internal policies. Applicant understands that disclosure may be required if necessary to adjudicate the claim or by mandatory reporting obligations; Authority will endeavor to notify Applicant prior to substantive disclosure where permissible.

7. REPRESENTATIONS, COOPERATION AND CERTIFICATION

Applicant represents and warrants that all information supplied in this application is true and complete to the best of Applicant's knowledge. Applicant agrees to cooperate fully with Authority in scheduling and attending the asylum interview and to provide truthful testimony and supporting documentation. Applicant understands that knowingly providing materially false information may expose Applicant to administrative or criminal penalties.

By signing below, Applicant certifies under penalty of perjury that the statements contained herein are true and correct, that Applicant requests scheduling of an asylum interview, and that Applicant authorizes Authority to contact Applicant or Applicant's representative at the addresses provided for purposes of scheduling and case administration.

8. AUTHORITY COVENANTS

Authority agrees to consider Applicant's stated preferences and accommodations in good faith, to notify Applicant or Applicant's representative of the scheduled interview date and location in writing, and to provide reasonably necessary interpretation services where indicated and available. Authority makes no guarantee of outcome by scheduling an interview.

9. NOTICES

All notices, requests, demands and other communications required or permitted under this application shall be in writing and shall be delivered to the addresses set forth below or such other address as a party may designate in writing.

10. AMENDMENTS, WAIVER, COUNTERPARTS

This application may be amended only by a written instrument signed by Applicant and by an authorized representative of Authority. No waiver of any provision of this application will be effective unless in writing signed by the waiving party. This application may be executed in counterparts, each of which will be deemed an original.

11. GOVERNING LAW, ENTIRE AGREEMENT, SEVERABILITY

This application and any dispute arising out of it shall be governed by the laws and rules applicable to Authority's asylum procedures. This application constitutes the entire written statement of Applicant's request for an asylum interview and supersedes any prior written or oral communications on the same subject. If any provision is held invalid or unenforceable, the remaining provisions will continue in full force and effect.

12. ADDITIONAL INFORMATION

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