PRICE Re. 1/ Form No. OFFICE OF THE ASANSOL MUNICIPAL CORPORATION ASANSOL Child's Name Quoted Affix To, Court fee Not Changeable The Mayor Stamp of Re.0.25 Asansol Municipal Corporation Asansol Sir, I am furnishing below the details of particulars of the birth, for which the birth certificate is prayed for: 1. Date of Birth / Still Birth _______________________________________________________ 2. Date of Application _______________________________________________________ 3. Name of the Child (Block) _______________________________________________________ 4. Place of Birth/ Still Birth _______________________________________________________ 5. Sex ________________________ 6. Age of the Child ________________________________ 7. Permanent residential Address of the Parent / Guardian ________________________________ 8. Father of the Baby 9. Mother of the Baby a) Name ________________________________ a) Name ______________________________ b) Literacy ______________________________ b) Literacy ____________________________ c) Occupation ____________________________ c) Occupation __________________________ d) Nationality ____________________________ d) Nationality __________________________ e) Religion & Caste _______________________ e) Religion & Cast ______________________ (S.C, S.T) (S.C, S.T) 10. Age of mother in completed years confinement ______________________________________ 11. Order of birth (i.e. No. of live births including the Birth Registered) 12. Type of medical attention received (if any) _________________________________________ 13. Informant's name and address (in Block letters) 14. Relation ____________________ 15. Whether applicant belongs any Ration Card within the area ____________________________ 16. In case of special permission from A.D.M., please enclose the Doctor's certificate and put the Memo Nos. of with date of permission achieved. Signature of LTI/ RTI of the informant with date (FOR OFFICE USE ONLY) Registration No. Date of Registration Remarks ________________________________________________________________________ Form No..... Name of the applicant: Fees Receiving Date: Monday, Wednesday, Friday Signature & Official Seal of the 1030 AM to 200 PM Receiving Clerk with date Downloaded from www.asansolmycity.com
