CONSULADO DEL PERU
‘AUCKLAND ~ NUEVA ZELANDIA-AUSTRALIA FOLIO Ne
REGISTRO DE NACIONALES
NOMBRE(S):
APELLIDO PATERNO:
APELLIDO MATERNO:.
ONK: PASAPORTE:
FECHA DE NACIMIENTO: LUGAR DE NACIMIENTO:
GENERO: FQ MO __ ESTADOCIVIL: EDAD:
PROFESION U OCUPACION:.
NUMERO DE TELEFONO(S):_(CASA), (CELULAR).
DIRECCION DOMICILIARIA EN NUEVA ZELANDIA:
‘CORREO ELECTRONICO:
DIRECCION DEL LUGAR DE TRABAJO:,
NUMERO TELEFONICO DEL LUGAR DE TRABAIO:.
APELLIDOS ¥ NOMBRE DEL PADRE:
NACIONALIDAD DEL PADRE:
PELLIDOS Y NOMBRE DE LA MADRE:
NNACIONALIDAD DE LA MADRE:
DIRECCION DOMICILIARIA DE PADRES O PARIENTES EN EL PERU:
NUMERO TELEFONICO DE LOS PADRES O PARIENTES EN EL PERU:
FIRMA DEL INSCRITO FILIACION DELA PERSONA
QUE SOLICITA CERTIFICADO
Applicant's Information
Nombres «..
‘Names
Naclonalidad
‘Nationality
Langer de Nacimiento.
Born at
Fecha de Necimiento....
Date of birth
‘Pessporte N°
Passport N
Residencia actual...
‘Actual residence
‘Ocupanién actual
Actnal ocupation
Motivo del Catificado
Cenificate given for
Fecha de tench
Datefilled
‘Nombre y Firma del Wdentifcadio
‘Applicants signature
NOTA: El recomente autoriza 2 Don/Dofa.
‘para que en su nombre
1 Cettificade correspondiente,
Aida Fiona Mac Donald
Lopez de Crombach
--. Consul Honoraria..
NOMBRE COMPLETO Y FIRMA DEL OF!
(FULL NAME AND OPERATOR'S SIGNS ATURE),
Left bond
i
POLIGIA NACIONAL DEL PERG
DIRECCION DE CRIMINALISTICA
DIVISION DE IDENTIFICACION CRIMINALISTICA
TOMA DE IMPRESIONES DIGITALES DE LA
PERSONA QUE SOLICITA EL CERTIFICADO
APPLICANT'S FINGERPRINTS
Right band
‘Awular
sRing. finger
Middle finger
Medio
Fore finger
Tndice
‘Mano Derecha
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