1/4

Le Greffe

The Registry

Application for permission to visit a detained person1 (Annex 1)

1 In accordance with Regulation 179 of the Regulations of the Registry “All visitors other than counsel, diplomatic or

consular representatives, representatives of the independent inspecting authority, or officers of the Court, shall first apply to the

Registrar for permission to visit a detained person.”

Instructions:

Complete this form. Try to be as detailed as possible in describing your relationship to the detained

person, for example:

• ‘Friend’ is not sufficient information: describe how long you know each other, from where

you know each other, when was the last time you met, etc.

• Family relationships should be described in detail, for example: ‘my mother is a sister of

the detained person’.

Mail, fax or e-mail this completed and signed form together with a legible copy of your passport

picture page to:

Mail: ICC

Att. Detention Centre

P.O. Box 19519

2500CM The Hague

The Netherlands

Fax: +31 70 515 8965

E-mail: detention.visits@icc-cpi.int

Telephone: +31 70 515 8080

Please note that:

• Visits depend upon the availability of facilities;

• Whenever an electronic application is used, you will be requested to sign your name on a

hard copy of the application form upon your arrival at the detention centre;

• Give at least 15 calendar days between this application and proposed visiting time;

• Due to unforeseen circumstances, the visit may not be authorised within these 15 calendar

days: you are therefore advised not to make any travel arrangements before your visit is

approved;

• This form consists of four pages;

• Incomplete and/or illegible forms will not be processed;

Detained person you wish to visit

Visitor Surname(s) (family name(s))

Surname(s) at birth (earlier family

name(s))

First names (given names)

Date of birth (day-month-year)

Place and country of birth

Visitor’s Father’s name

Visitor’s Mother’s name

CONTINUE ON PAGE 2

2/4

Present address

Permanent Address

Address while in The Netherlands

(or of country of stay during the

visit)

Telephone numbers:

Residential:

Mobile:

Local number in Europe:

Fax number

E-mail address

Nationality

Number of passport

Issued by

Date of issue

Valid until

CONTINUE ON PAGE 3

3/4

State in detail your reason for the

visit.

Describe in detail your relationship

to the detained person.

Name of Employer:

Work Address:

Work Telephone number:

Job Title:

Employed since:

If student, name of university/school

and address:

Political Role:

Have you served in the Political

Party of any country?

If yes, state the name of the Political

Party and your role.

Military Role:

Have you served in the Armed

Forces of any country?

If yes, describe the nature of your

services. State your position, rank

and duration of service.

If you were discharged, state the

date and reasons for discharge.

As a member of the Armed forces,

were there any charges or

proceedings instituted against you?

CONTINUE ON PAGE 4

4/4

If yes, provide sufficient details of

the charges and the final decision in

the case.

Criminal Record:

Have you ever been arrested for any

crime in any country including the

country of your birth, nationality,

residency or any other? If YES,

provide details on the charges

against you, the city, state and

country and dates of your arrest.

Have you ever been found guilty of

a crime in any country? If YES,

provide details on the charges, the

sentence, name and location of the

penitentiary and the dates when you

served your sentence.

Do you have any particular role or

status in respect to the ongoing

proceedings?

Requested visiting date and time:

(NB: If unspecified, visits will be

scheduled for an hour

approximately 20-25 calendar days

from the receipt of this form. You

may be required to submit a new

form to re-schedule visits.)

Have you previously visited the

detained person? If so, when was

the last time?

Which languages do you speak?

I confirm that all information I have provided is correct and that the Detention centre may

inquire further if it so wishes. I declare that I shall not disclose any information to the media.

Date _______________________ Signature _______________________________

Version 1, English