| Preliminary Information: |
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| Family names and name of person offering information: |
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| Contact (address, telephone, e-mail, etc): |
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| Date |
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| General Information of exiled person: |
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| Family names and name |
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| Place and date of birth |
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| Place and date of death |
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| Profession (from 1936-39) |
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| Armed forces |
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| Rank |
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| Political affiliation |
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| Union affiliation |
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| Positions as political, syndical, cultural or other, representative (“casinos”, associations, etc.) |
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| Border town or pass used to leave the country: |
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| Exile |
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| Place of residence or detention centre/s in France or other places (names of places or camps, and dates): |
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| Leaving the camps |
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| Work contract, maquis or French Resistance, work battalions or other situations (places and dates, type of work, etc.) |
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| Deported to Nazi Concentration Camps |
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| Place and date of detention |
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| Camp/s and dates |
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| Survivors (place and date of liberation) |
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| Death (place and date) |
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| Place of residence after leaving the camp |
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| Travel and exile to another country (America, Europa, Africa, etc.) (place and date) |
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| Transportation, name of vessel (in case of sea ships), and dates. |
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| Residence (permanent or temporary, places and dates) |
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| The return |
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| First time back |
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| Entrance border and date |
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| Resulting situation: return home, arrest and prison, other forms of repression (place and dates) |
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| Definitive Return |
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| If YES, please specify place of residence |
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| Definitive Return |
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| Place of residence and date |
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| Observations |
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| Complementary_Information |
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| Do you have any documentation (personal writings, printed material of the time, photographs, etc.)? |
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| I have read and accept the legal conditions of the MUME Consortium * |
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