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Application form for archive investigation by Stichting SJOA
Name of applicant:
Address of applicant:
Telephone number of applicant:
Hereby requests, etc. ............................................................................(complete sentence)
Full first names and surname of the individual in question: .................................................
Date and place of birth of the individual in question: ...........................................................
Date and place of death of the individual in question: .........................................................
Name of the spouse of the individual in question: ...............................................................
Last known address(es): .....................................................................................................
Details in relation to the life insurance
Name of insurers: ...............................................................................................................
Policy numbers: .................................................................................................................
Other information on the policy: ..........................................................................................
What is your relation with the individual in question? .............................................................
By means of this application the undersigned authorises Stichting Sjoa to review relevant information on the individual in question in the archives.
Applicant's signature:
.............................................................................................................................................
Date ....................................................................................................................................
(A separate application form must be submitted per person)