Guyana immigration form

*Information to be supplied by persons
desirous of immigration into Guyana.

1. Full Name (Block Capitals, surname first) STOEN, Jon Victor

2. Address: 6300 Eastside Calpella Road, P.O. Box 126, Ukiah, Calif.

3. Nationality U.S.A.

4. Date of Birth January 25, 1972

5. Place of Birth Santa Rosa, California

6. Profession, trade or occupation N/A

7. Married or single Single

8. Wife’s (Husband’s) name and nationality N/A

9. Names and dates of birth of dependent children N/A

10. Schools and other educational institutions attended and periods of attendance N/A

11. Academic, Professional, Technical, and other qualifications N/A

12. Assets (including cash) Assets are to be imputed to the Peoples Temple Agricultural Mission in Guyana (which has leased land under the Government’s FCH program).

13. State whether you are prepared to work and live in the interior of Guyana Yes

14. Details of the farming experience N/A

The applicant is a member of Peoples Temple’s Agricultural Mission in Guyana. All such applications are to be processed through the Ministry of Home Affairs.

Declaration: I certify that to the best of my knowledge and belief the foregoing statements are true and made in good faith.

[signed] Grace L. Stoen

* The applicant is also requested to submit, together with the information furnished above, a certificate for the police authority for the country (or countries) where he (she) has been resident during the last ten (10) years, to the effect that there has been no conviction against him (her).