APPLICATION FOR BIRTH CERTIFICATE

(Write in Capital Letters)

CIRCLE/LOCALITY :
1. ate O! Birt" :
#. $e% :
&. C"il' Na(e :
a) If Registered Mention the Child Name.
)) If Child Name not included a separate form to be filled by the Father and
Mother of the child
*. Na(e +! t"e Fat"er :
,. Na(e +! t"e -+t"er :
.. Pla/e +! Birt" :
(Tick the appropriate entry a0 )0 / below and gie the name of the !ospital"InstituTe or the
#ddress of the !ouse where the Birt" took place.If other place gie location$
a) H+spital/Instit1ti+n Na(e :
)) H+1se A''ress :
/) Ot"er pla/e :
2. N+.O! C+pies Re31ire' :
4. a) + 5+1 6ant t"e Birt" Certi!i/ate )5 C+1rier7 Yes / N+
)) I! Yes 8i9e Na(e an' A''ress 6it" PinC+'e

Na(e : a''ress0 ($i8nat1re +! t"e
Appli/ant)
Telep"+ne N+:
Note%& 'irth certificate will be issued sub(ect to entry found Registered with ;H-C records.
e$e9a Transa/ti+n N+: e$e9a Transa/ti+n ate: