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ಬೆಂಗಳೂರು ಮಹಾನಗರ ಪಾ.ಕೆ

BANGALORE MAHANAGARA PALIKE

BMP-HE-E-DEC03-F-110

Statistical Section

Health Department

BMP-HE-E-DEC03-F-110

APPLICATION FOR BIRTH CERTIFICATE

APPLICANT INFORMATION ñPrint(bold letters or type)

1 Name of Applicant- First Name Middle Name/Initials Last / Surname

2 Address :number, street locality City/Town/Village Dt/Taluk/PO State Pin code

3 Telephone Number 4 Purpose for which certificate is to be used 5 Relationship with subject

6 Name of person receiving certificate(s), if

different from applicant

7 Number of copies 8 Amount Paid

CERTIFICATE INFORMATION ñ Print (bold letters) or type

9 Name of the Mother ñ First Name Middle Name/Initials Last /Surname

10 Name of the Father- First Name Middle Name/Initials Last/ Surname

11 Date of Birth

dd mm yyyy

/ /

12 Sex

! Female ! Male

13 Place of Birth

! Hospital ! Other

14 Place of Birth (Full address) City State Pin code

15 Name of Hospital (If born in hospital)16 Date of Registration (if available)

dd mm yyyy

/ /

17 Registration Number

(if available)

DECLARATION

I hereby state that the above information is true and request for the certificate.

18 Date : dd mm yyyy

/ /

19 Signature/Left thumb print

DO NOT WRITE IN SPACE BELOW ñ FOR OFFICE USE ONLY

20 Name of SHO 21 Registration Number

22 Date of event: dd mm yyyy

/ /

23 Signature of the concerned case worker

24 Receipt Number 25 Date of Payment : dd mm yyyy

/ /

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