CHANDIGARH ADMINISTRATION REGISTRAR BIRTHS & DEATHS e-JAN SAMPARK Application for Issue of Birth Certificate(s) FOR OFFICE USE ONLY Total Amount ___________ To Number of Copies _______ The Registrar, Receipt Number _________ Births and Deaths, U.T., Chandigarh. Dated : ______/_____/____ Sir, Kindly issue me the Birth Certificate(s) as per details given below : 1. Date of Birth (dd/mmm/yyyy): _______/_______/________ 2. Sex : Male Female (Tick one) 3. Place of Birth (Complete Address) : ______________________________________ __________________________________________________ 4. Father's Name: _______________________________________________________ 5. Mother's Name: ______________________________________________________ 6. Grand Father's Name: _________________________________________________ 7. Permanent Address at the time of admission in Hospital/Nursing Home: ___________________________________________________________________ 8. Relation of Applicant with Child (Father/Mother/Relative): e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 1 of 2 CHANDIGARH ADMINISTRATION REGISTRAR BIRTHS & DEATHS e-JAN SAMPARK 9. Registration Number (if applicant knows) _________________________________ 10. Registration Date (if applicant knows) ____________________________________ 11. Name of Child (with application on bond Paper) ____________________________ FOR OFFICE USE ONLY Instructions to Dealing Hand in case of any correction filed by the applicant : Corrected Particulars with the date of correction: Child Name (if any): ____________________________________________ Name of Father: ________________________________________________ Name of Mother: _______________________________________________ Sex: _________ (DOC: ____/____/____) Date of Birth: _____/_____/_____ (DOC: ____/____/____) Place of Birth: ___________________________ (DOC: ____/____/____) DOC - Date of Correction Signature of Receiver with Date of receiving ______________ ______/______/_______ e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 2 of 2
