This document is a blank pledge for individuals seeking to leave Iraq and al-Qa`ida in Iraq. The document requires the individual to fulfill a number of requirements and to pledge to not to divulge any information about his activities in Iraq | to agree that the al-Qa`ida organization does not bear any responsibility for him after he leaves Iraq | to not leave Iraq without orders | and to acknowledge that his personal rights are forfeited if he leaves Iraq without permission. The document is completed by the individual providing his name, number, alias, signature, and

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