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I think the pronouns may have been mistranslated or miss-used. I would definitely ask the person who sent this to you to clarify. (I think the “at” is “on” and the “on” is “at”). Having English as my second language my guess is as follows:
BLANK 1 - country where you were born
BLANK 2 - date of birth
BLANK 3 - current residence
BLANK 4 - current date
Better than doing some guess work ask for clarification; you don’t want to fill in immigration forms / work permits wrong.