IOM Case Number:
VOLUNTARY ASSISTED RETURN AND REINTEGRATION PROGRAMME
(IRELAND)
The International Organization for Migration DOES NOT CHARGE A FEE AT ANY STAGE of the Voluntary Assisted Return process. This is a free and confidential service.
FOR IOM USE ONLY
IOM Case Number: Immigration/Asylum
Ref. Number/s:
Date of Application: Requires Travel
Doc/Visa/IE TD:
Age at Date of Number Passengers
Application: Travelling:
TO APPLICANT OR APPLICANT’S REPRESENTATIVE:
Please complete this form in BLOCK CAPITALS.
1.
Family Name/s:
First Name/s
Date of Birth: Sex: Male Female
Place of Birth: Nationality: Nationality:
Marital Status: Citizenship:
Address in Ireland:
Telephone No: Referral Agency:
(How did you hear
about IOM?)
Immigration Status:Asylum application pending
Asylum application refused
Asylum appeal pending
Asylum appeal dismissed
Leave to Remain/Pending (HLR)
Other (please specify):
2.Date of exit from Country of Origin: Date of last entry
into Ireland:
Date applied for Asylum:
Passport/Travel Doc: Yes No Date of Expiry:
Location (Is it with you?):
Documents held by Immigration:
(ID card, Driving License, etc)
3. Family Members returning with you:
First Name
/ Date of Birth /Sex
(M/F) / Relationshipto Applicant / Citizenship / Passport Expiry Date / Immigration/ Asylum Ref. No.
Family Name
4.Reasons for Wishing to Return:
Would you like to apply for reintegration assistance from IOM: Yes / No
Special Needs (Wheelchair or other medical requirements):
(Please note that IOM may need to share information on medical issues with the third parties in order to provide medical assistance)
Final Destination in Country of Origin (please state full address):
Town of Destination:
Closest Airport:
VOLUNTARY ASSISTED RETURN
AND REINTEGRATION PROGRAMME IRELANDDeclaration of Voluntary Return
FOR IOM STAFF/PARTNERS: Each individual who may be considered/be eligible for IOM voluntary return assistance must be able to understand and consider the content of this form before signing. Please allow the individual to read the form (or ensure it can be translated in a language understood by the applicant); and explain it before asking him/her to sign the voluntary declaration.
I, the undersigned, ______, express my informed decision to return
voluntarily to my home country, which is ______, through the assistance of IOM.
I understand that IOM will assist me to return home, and I will not be allowed to stop over in any transit country.
I understand that the details requested on the Voluntary Assisted Return and Reintegration Programme (VARRP) application form are required by the Irish Immigration Authorities in order to assess eligibility to participate in the VARRP. I consent to the Immigration Authority using the information in order to assess, in the exercise of functions under the Immigration Law, whether I am eligible to participate in the Voluntary Assisted Return and Reintegration Programme.
In addition, I state that I do not have any outstanding criminal or civil proceedings in the Republic of Ireland. I am not wanted by the Irish Authorities in connection with the commission of any crime.
I agree for myself as well as for my dependants, heirs and estate that, in the event of personal injury or death during and/or after my participation in the IOM programme, neither IOM, nor any other participating agency or government can in any way be held liable or responsible.
I understand that if I make a false statement in signing this form, the assistance provided by IOM can be terminated at any time.
Signature of the applicant / DateSignature of the Representative of IOM
/ DateMission in Ireland:116 Lower Baggot Street, Dublin 2.Freephone: 1800 406 406
Tel:+353 (0)1 676 0655Fax:+353 (0)1 676 0656Email:eb: