REGISTRATION FORM

1. Family Name: 2. First Name:

3. Middle Name: 4. Gender: Mr. Mrs. Miss.

5. Father’s Name: 6. Mother’s Name:

7. Date of Birth – dd/mm/yyyy: 8. Place of Birth:

9. Nationality: 10. Marital Status:

11. Eyes Color: 12. Hair Color:

13. Body Height: 14. Distinguished Marks:

15. Profession: 16. Diplomas:

17. National ID / Passport - Number: 18. National ID / Passport – Issuing Country:

19. Home Address: 20. Email Address:

21: Cell Phone Number: 22. Fluent Language(s):

23. Do you want to become a Permanent 24. Do you want to become a Member of the
Atlantean Citizen? YES NO KOA Government? YES NO

I declare that the information supplied on this form is complete, correct and up-to-date in every
detail. I understand that if I have given false or misleading information, my application may be
refused. I undertake to inform T H E K I N G D O M O F A T L A N T I S of any material changes to
my circumstances while my application is being considered. I declare that I have read and
understood the information supplied to me and in particular the information contained in
this Registration Form.

Date: Signature:

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 PASSPORT/NATIONAL ID & PHOTO
Please send us a copy of your Passport or National ID and a Good Quality Picture of
yourself in Passport Format with white background.