This application form can’t be sent via Internet! Please fill out, print out and send to
Bundesamt für Justiz after authentification.
Bundesamt für Justiz
- Bundeszentralregister Sachgebiet IV 21 / IR
53094 Bonn
GERMANY
Print out application form
if available: File No:
IV 21 –
D
I apply for a Certificate of Good Conduct (please tick appropriate box),
please send it to my private address.
please send it to the German office as per particulars given below. (It is not possible to send Certificates
of Good Conduct to foreign offices!)
The fee for the Certificate of Good Conduct of 13 € (please tick appropriate box)
has already been paid by me.
has been transferred on
to
Deutsche Bundesbank - Filiale Köln is enclosed (check).
bank code: 370 000 00, account number: 38001005
BIC: MARKDEF1370,
IBAN-number: DE49370000000038001005
to Bundesamt für Justiz.
(Please attach proof of payment, e.g., copy of paying-in-slip.)
My personal data are:
Family name at birth:
Present family name:
All first names:
Date of birth:
Place of birth:
Nationality:
Present private address:
Signature of the applicant:
The above signature and personal data are herby authenticated:
Seal
Date
Embassy
Authority
Office
Consulate
Notary Public
Police Station
Additional information for sending the Certificate of Good Conduct to a German office:
Intended use:
Name of the office:
Address of the office:
Print out application form
Street address:
Adenauerallee 99-103
53113 Bonn/Germany
www.bundesjustizamt.de
Postal address:
53094 Bonn
Germany
Phone:
+49 228 99410-5668
fax:
+49 228 99410-5050
Consultation hours:
mo-fri 9-11 Uhr
mo-thu 13.30-15 Uhr