COUNTER BIRTH CERTIFICATE COUNTER BIRTH CERTIFICATE COUNTER BIRTH CERTIFICATE

16-17 Request Form 16-17 Request Form 16-17 Request Form

DATE FILED: DATE FILED: DATE FILED:

NAME: NAME: NAME:

DATE OF BIRTH: DATE OF BIRTH: DATE OF BIRTH:

PLACE OF BIRTH: PLACE OF BIRTH: PLACE OF BIRTH:

FATHER’S NAME: FATHER’S NAME: FATHER’S NAME:

MOTHER’S MAIDEN NAME: MOTHER’S MAIDEN NAME: MOTHER’S MAIDEN NAME:

REQUESTED BY: REQUESTED BY: REQUESTED BY:

ADDRESS; ADDRESS; ADDRESS;

CONTACT NUMBER: CONTACT NUMBER: CONTACT NUMBER:

RELATION TO THE OWNER: RELATION TO THE OWNER: RELATION TO THE OWNER:

NO. OF COPIES NO. OF COPIES NO. OF COPIES

[ ] Certified True Copy _______ [ ] Form 1A _______ [ ] Certified True Copy _______ [ ] Form 1A _______ [ ] Certified True Copy _______ [ ] Form 1A _______
To be filled up by the office To be filled up by the office To be filled up by the office
REGISTRY NUMBER: REGISTRY NUMBER: REGISTRY NUMBER:

[ ] WITH Remarks [ ] Without Remarks [ ] WITH Remarks [ ] Without Remarks [ ] WITH Remarks [ ] Without Remarks
Verified by: [ ] Counter 16 [ ] Counter 17 Verified by: [ ] Counter 16 [ ] Counter 17 Verified by: [ ] Counter 16 [ ] Counter 17
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BIRTH CERTIFICATE CLAIM STUB BIRTH CERTIFICATE CLAIM STUB BIRTH CERTIFICATE CLAIM STUB
( Claim at Counter 18 ) ( Claim at Counter 18 ) ( Claim at Counter 18 )
REGISTRY NUMBER: REGISTRY NUMBER: REGISTRY NUMBER:
NAME: NAME: NAME:

DATE RECEIVED: DATE OF RELEASE DATE RECEIVED: DATE OF RELEASE DATE RECEIVED: DATE OF RELEASE
[ ] Certified True Copy _____ [ ] Form 1A _______ [ ] Certified True Copy _____ [ ] Form 1A _______ [ ] Certified True Copy _____ [ ] Form 1A _______
Not the owner of the document Not the owner of the document Not the owner of the document
No Valid ID No Valid ID No Valid ID
Needs authorization letter & Valid ID Needs authorization letter & Valid ID Needs authorization letter & Valid ID
REMARKS REMARKS REMARKS

ATTENDING PERSONNEL: ATTENDING PERSONNEL: ATTENDING PERSONNEL:

Date: Date: Date: