OFFICE

OF THE PRESIDENT
CIVIL REGISTRATION SERVICES

APPLICATION FOR A BIRTH CERTIFICATE CBC-RPSYZOM

FORM B4 FEE: 180 DATE: FRI 31 MARCH 2023

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 PRINT DATE

NAME OF CHILD KIPLAGAT KIPTOO NAME OF REGISTERING OFFICER

CHILD ABOVE 18? YES RECORD CHECK BY

CHILD ID NUMBER 25230567 ASSESSED BY

DATE OF BIRTH 01-03-2023 APPROVED BY

SEX OF THE CHILD MALE

ENTRY OR NOTIFICATION NUMBER

DETAILS OF FATHER AVAILABLE? NO

DETAILS OF MOTHER AVAILABLE? YES

NAME OF THE MOTHER ESTHER JEROTICH CHEMNJOR

ID NUMBER OF THE MOTHER 1119058

NAME OF THE GUARDIAN

ID NUMBER OF THE GUARDIAN

ADDRESS OF THE APPLICANT LANGATA

SIGNATURE

APPLICANTS NAME KIPLAGAT KIPTOO TELEPHONE NO +254701051510

DATE PRESENTED FRI 31 MARCH 2023 PICK UP LOCATION ACK BISHOP