OFFICE

OF THE PRESIDENT
CIVIL REGISTRATION SERVICES

APPLICATION FOR A BIRTH CERTIFICATE CBC-AQSWE3E

FORM B4 FEE: 180 DATE: FRI 04 NOVEMBER 2022

TO BE COMPLETED IN CAPITAL LETTERS FOR OFFICIAL USE ONLY

TYPE OF APPLICATION NEW ENTRY NUMBER

COUNTY OF BIRTH NAIROBI APPLICATION NUMBER

EXACT PLACE OF BIRTH PHADAM HOSPITALPINE MEDICAL PRINT DATE

NAME OF CHILD KYLA CHEMUTAI KIPTOO NAME OF REGISTERING OFFICER

CHILD ABOVE 18? NO RECORD CHECK BY

DATE OF BIRTH 23-09-2022 ASSESSED BY

SEX OF THE CHILD FEMALE APPROVED BY

ENTRY OR NOTIFICATION NUMBER

DETAILS OF FATHER AVAILABLE? YES

NAME OF THE FATHER PETER KIPTOO KORIR

ID NUMBER OF THE FATHER 31900427

DETAILS OF MOTHER AVAILABLE? YES

NAME OF THE MOTHER DOREEN GACHERI

ID NUMBER OF THE MOTHER 33391026

NAME OF THE GUARDIAN

ID NUMBER OF THE GUARDIAN

ADDRESS OF THE APPLICANT UTHIRU GICHAGI

SIGNATURE

APPLICANTS NAME PETER KIPTOO KORIR TELEPHONE NO +254712040811

DATE PRESENTED FRI 04 NOVEMBER 2022 PICK UP LOCATION ACK BISHOP