Application Form for Birth Certificate 1. Name of Applicant : ....................... 2. Name of the Child ....................... 3. Date of Birth : ....................... 4. Place of Birth : ...................... 5. Birth Report from Local Gaonburah/Civil Hospital /Local P.H.C./Nursing Home : ........................ 6. Affidavit duly signed by magistrate in case of Delay for more than one year : ........................ 7. In case of student, Certificate to be submitted duly Counter signed by the inspector of schools : ........................ 8. Date of Application : ........................ ........................... Signature of Applicant ....................................... Enclosed: 1. Affixed Rs.1.10 for court fee stamp. 2. Birth Report from Local Gaonburah/Civil Hospital/Local P.H.C./Nursing Home 3. Treasury Challan copy
