1.

Familiyasi

Family name

Ismi

First name

Otasining ismi

Patronymic

2.

Tugʻilgan sanasi (kun, oy, yil)

Date of birth (day, month, year)

Tugʻilgan joyi

Place of birth

3.

Fuqaroligi

Present nationality

4.

Shaxsini tasdiqlovchi hujjat

Identification document

Raqami

Number

Berilgan vakti

Date of issue

Qachongacha haqiqiy (kun, oy, yil)

Date of expiry (day, month, year)

5.

Siz qaysi tillarda soʻzlashadi

Knowledge of languages

6.

Ish joyi (toʻliq nomlanishi, manzili, telefon, faks)

Place of work (full name, address, phone, fax of the organization)

7.

Lavozimi

Position/Designation

8.

Siz xalkaro (xorijiy) kuzatuvchi sifatida vakili boʻlgan tashkilot nomi

Name of organization/state You represent as foreign (international) observer

Telefon (faks)

Phone (fax)

9.

Uy manzili

Present home address

Telefon

Phone

Faks

Fax

E-mail

10.

Xorijiy xalqaro kuzatish tajribasi, shu jumladan Oʻzbekistonda (mamlakat, yil, qaysi missiya tarkibida)

Experience from election observation, including in Uzbekistan (country, year, mission)

11.

Oʻzbekiston Respublikasiga kelish sanasi

Date of arrival to the Republic of Uzbekistan

12.

Oʻzbekiston Respublikasidan ketish sanasi

Date of departure from the Republic of Uzbekistan

13.

Sana

Date

Imzo

Signature