APPLICATION FORM BIRTH CERTIFICATE LATE ENTRY ORDER (Please atte sot foe stam) aidumarted with") ara mandinery Applied By* Father's/Husband’s Name* Date of BirthiAga* Mobile No* Phokomaph ofthe coma y, : person ( on whose name Birth Relat i h Relation of Applicant with /T) Father (Grand Father Canthicate iets lath child / person po O Mother Grand Mather Gender* Male Cifemale (Transgender = = -| (This phota is for seanning de not Aadhaar No, rons sign} E-mail House No / Flat No* Sector Village” Tehsil / Subistrict* Distriet* State/UT* Pin Code* ‘Child/ Person Details (on whose name Birth Certificate Late Entry will be Issued) : Name* Father's Name* Gender* [Male (>) Femsia() Transgender —_| Mother's Name* Birth Details: Birth Date Order of Birth* Birth at® [Di ovecrment Hospital || PGIMER or Pu. Hospital ci Homeyother ‘Address of Place of Birth in case of Birth at Hospital: Hospital Name” [)SMCH, Sector 32, Chandigarh C] GMSH, Sector 16, Chandigath (in caveat epic) ie est ‘Flan rant boa ir) Address of Place of Birth and Dal Details in case of Birth at Home/ Others: Complete Address of Birth* fin cose of homejothersenty} Dai Name* Registration No* Jn tne of homefethans tole) case othornefoters only) ‘Sell-Undertaking Tis sie Photograph of the Aged resident of ee en ene age vouuy verity | person applying for that the above contents and supporting documents aie correct to the best of my Knowledge and belief and | the certificate with ‘othing has been concealed therein am aware that in case the information fumished above is foundto be | eros signature incorrect, | shall be Kable for prosecution under Section 177 & 191 af the Indian Penal Code, which stipulates lmgeisonment and fiee. mae SS Rai ss -Sen/Daughter of Sh. Pa on . Name "Without creas signature (half on paper and half on photograph) and signature on undertaking the application will be rejected