Form 'A" (Application for change of name or surname under the Goa Change of Name and Surname Act 1990) MODEL 'A' (See rule a) 1. Name of the applicant as entered in his/her birth certificate: ............... 2. Father's name: ............... 3. Mother's name: ............... 4. Sex: ............... 5. Date of Birth: ............... 6. Place of Birth: ............... 7. The name, surname or both of the applicant required to be changed from .............. (Old name/surname/both) to ............... (new name/surname/both) 8. Name of the applicant as it would appear after the name at serial no.1 be changed: ............... 9. The reason for such change (to be supported by an affidavit) ............... 10.Whether the applicant had applied earlier for change of name, surname or both: ............... 11.If yes, whether the application was granted or not: ............... 12.If the application was granted whether the certificate regarding changed name has been attached: ............... 13.If the application was rejected, the reasons therefore: ............... 14.Name of the guardian if the applicant is Minor: ............... 15.Guardian's relationship with the applicant: ............... (..............) Signature of the applicant or of his/her guardian. Note: Birth Certificate of the applicant should be attached to the application alongwith Affidavit. *Fee Rs.36/- (Rupees Thirty six only) Address of applicant.
