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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
TO APPLICANT OR APPLICANT’S REPRESENTATIVE: Please complete this form in BLOCK CAPITALS.
1. Family Name/s:
Date of Birth:
Place of Birth:
Address in Ireland:
Referral Agency: (How did you hear about IOM?)
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:
Date of Expiry:
Location (Is it with you?):
Documents held by Immigration:
(ID card, Driving License, etc)
3. Family Members returning with you:
4. Reasons for Wishing to Return:
Would you like to apply for reintegration assistance from IOM:
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: