I. IDENTIFIER INFORMATION — for Individuals | Where possible, note the nationality or cultural or ethnic sources of names/aliases. Provide all available spellings. | Surname/ Family Name/ Last Name | First Name | Additional name (e.g. father’s name or middle name), where applicable | Additional name (e.g. grandfather’s name), where applicable | Additional name, where applicable | Additional name, where applicable | Full Name: (in original and Latin script) | Aliases/“Also Known As” (A.K.A.s): Note whether it is a strong or weak alias. | Current | Former | Other nom de guerre, pseudonym: | Title: Honorary, professional, or religious title | Employment/Occupation: Official title/position | Nationality/ Citizenship: | Date of Birth: (DD/MM/YYYY) | Passport Details: (Number, issuing date & country, expiry date) | Alternative Dates of Birth (if any): (DD/MM/YYYY) | National Identification Number(s), Type(s): (e.g. Identity card, Social Security) | Place of Birth: (provide all known details including city, region, province/state, country) | Address(es): (provide all known details, including street address, city, province/state, country) | Alternative Place(s) of Birth (if any): (city, region, province/state, country) | Previous Address(es): (provide all known details, including street address, city, province/state, country) | Gender: | Languages spoken: | Father’s full name: | Mother’s full name: | Current location: | Previous location(s): | Undertakings and entities owned or controlled, directly or indirectly by the individual (see UNSCR 1617 (2005), para. 3): | Website Addresses: | Other relevant detail: (such as physical description, distinguishing marks and characteristics) | IDENTIFIER INFORMATION — For Groups, Undertakings, or Entities | Name: | Also Known As (A.K.A.s): Where possible, note whether it is a strong or weak A.K.A. | Now Known As (N.K.A.s) | Formerly Known As (F.K.A.s) | Address(es): Headquarters and/or branches. Provide all known details, including street address, city, province/state, country | Tax Identification Number: (or local equivalent, type) | Other Identification Number and type: | Website Addresses: | Other Information | II. BASIS FOR LISTING May the Committee publicly release the following information? Yes No May the Committee release the following information to Member States? Yes No Complete one or more of the following: | (a) participating in the financing, planning, facilitating, preparing, or perpetrating of acts or activities by, in conjunction with, under the name of, on behalf of, or in support of Al-Qaida (AQ), Usama bin Laden (UBL), or the Taliban, or any cell, affiliate, splinter group or derivative thereof.1 Name(s) of cell, affiliate, splinter group or derivate thereof: ______________________________________________________________________________ | (b) supplying, selling or transferring arms and related materiel to AQ, UBL or the Taliban, or any cell, affiliate, splinter group or derivative thereof.1 Name(s) of cell, affiliate, splinter group or derivate thereof: ______________________________________________________________________________ | (c) recruiting for AQ, UBL or the Taliban, or any cell, affiliate, splinter group or derivative thereof.1 Name(s) of cell, affiliate, splinter group or derivate thereof: ______________________________________________________________________________ | (d) otherwise supporting acts or activities of AQ, UBL or the Taliban, or any cell, affiliate, splinter group or derivative thereof.1 Name(s) of cell, affiliate, splinter group or derivate thereof: ______________________________________________________________________________ | (e) Other association with AQ, UBL or the Taliban, or any cell, affiliate, splinter group or derivative thereof. Briefly explain nature of association and provide name of cell, affiliate, splinter group or derivate thereof: ______________________________________________________________________________ | (f) Entity owned or controlled, directly or indirectly, by, or otherwise supporting, an individual or entity on the Consolidated List.2 Name(s) of individual or entity on the Consolidated List: ______________________________________________________________________________ | Please attach a Statement of the Case which should provide as much detail as possible on the basis(es) for listing indicated above, including: (1) specific information supporting the association or activities alleged; (2) the nature of the information (e.g., intelligence, law enforcement, judicial, media, admissions by subject, etc.) and (3) supporting information or documents that can be provided. Include details of any connection with a currently listed individual or entity. Indicate what portion(s) of the Statement of Case the Committee may publicly release or release to Member States.