N FoRJ,,!

84
OFEICE OF TIIE PRESIDENT

DEF.4R.T'ME,}IT OF C[v&, REGISTRATION

A.PPLXC.{T'ION FOR. BIR,TH CER.TIFICATE

!. Sub-county of birth

2. Counf of birth Z. Descrfxion of informant..-..

3. NotificationNo. .................
4" Exact place of birth....-.-...-.- 3. Name of registering officer...........

5. Name of cbild 4. Date of rcgistration

5. R.ecord checked by

6. Date checked.."

9- Assessed by.,.-.

I0. Name of applicant and address 10. Date assessed ...........

12. Approve.d by

-..--------
Applicant's n:rme "" Mobile phone No,."
Child's name... ""Date of trirth..
F)ate presented .".,."..,"..".""".."""App1icatioo number...
 .'.,,;"
:',:,..

' REP!- ttl!( ',f KgiNlA,

IIiE BIgaHS rl\I.lt Db:4.11rs PJ-iirsI'RATTO'"1A(-l {C:aF- !4e}
REOISTER OT. EIRTIE
Scrial No. BC
2{ 67S?
t. ,'.A.]ME 2 D,aIE (}F BTR?H
O&il r!6rr!e M!nl5
t sEr' ]', TYPE OP BIRTII' ur,ref, spc.i8. . 5. N^I'IJRE OF ritF-IH+
-.l I{aleLl l (.'tIk|-l singe 'trrxn
f,J i-l Bom Ati* [_] Bors Ecad I
ILTiGHT{lFBIETII
?. PT.ACE OI AIRTH ,.,*- q iB*lre *,ld foR'o
Sub lo.atioo hr'rtah n5riftrtrJrr EitbEr

s. lrAr{E
First n&!ie N$ddle lelnc Fs$Er's lenrf,
9- AGE _;.*.__."-^*...-_

1O, MARITN- Sf,ATUS: i) MarxiEif E bi Ditrwr:d I c] Si.Ete tr di wi**/cd []

d rI. NANOT{AI.TTY r2.occirPA'llglr
.i- fr- ID- Irrrrlb.r.?asspo Alian Eard NurEber-----..-. la. LevE! of lXrBri6it

15. usuAlRr.slDrNcE ..---** __-.-.._-/ ---

Sd,.tdcaliod ot fJri& srd Toi{d Dilrrica .

16- PAJElIIOUS Brffi!{S 10 MOT}IE& .No. hxo &ti}c No- trlro dtud
(.rEl!di!f ofi.{ron )

E Firsa ,&iE Otk iEltle Fdkrl r6re

!9. IB, catrdNuBb€d

7e" 1{AAffi ----...

f!f5t@@-
i". -."
: a.4Pi.r'::71.' r-:- r::ff,8i"!A*1-
I fatar fi. TS.A [f Mid*-i& iJ!Edi.5!ar&eBca$ ;.: Olk , $g*ia,
11 q8tri-ll Ai!
H.
& I e*et!& &t ts &e
besr olil€r kosledge lfuai :!le isfillitrsxisB :2, i:].erE at F

Fje6 rrbo\'e is c-orreas-

t+
ID- li$E6a'PEq}a{tAlicnEardNt6*E{ Da-.'. LiaEtit
z
!j 2{. DAIE 25. REGISTft,qTIOll ASsISrA.iI? It a. 26.. i{,..$trE .4N1} S!{iNAT-1JRE
FF , {SErc iolFlodio,r q Lelib iaait*im}
.:-._-.-
tl Ikv Merrrr Y.8
tt- .?8. RE(ilSTfi.1t!'IOtl Nc.
--*-**:-..*.*
F
a9- 3t- sKiNriruRE *.*--
. G\rs tbc r*plFia(E to8, lhd8 (E)
+ if moilGt is irol'tnrrntd ro Hlct do Gol iBErt ol. eaftc qf fa&4.

t4,',t
r:i'r

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 .R-ElI-Dr.liC IOJF KEht!.li ,troiEo JB:r

DEFAMT'I\4EIVT O]F T'HE ItEc{stlt llt{-cEr{trll*4rr

Ap*[,,dcA,r[#]d,m'*]t &AT'fl R EG,SF,*ATX*N 0].F -4 8],[&T'SS

Please eo ryletu this forn and
,
t'ttrut fi, togethei witlt E cofl.ect{ee, to ttrc Dti .ict Regislrur
itt lctur disirict

A NNTOMMAT\ON NECAXTJDX}iG
IFNE C']E{IT-D

l. I'IAME

-ha !l tet,s. oarne (sriararre)

2. D4rE oF tsRru',_,,.**__**,.,_-, 'b;r----""--T;;i;*** *ffi; - 3. S!x: Male/Fcmalci,

{i h.AcE oF BnTn
Kijili and sub-locauon or streel aDd tol,rn /
j" llaME or .F}TEI
Dis'tricr
First l]ame Tribal (niddlt) nalne
6 NAr.fibl MorER i
-Fathc.r's natte -**.*
kunnnc)
First Dalle
Tiibal Qniddle) DAAIe -t"a tter's or irrrsband'st
7. YEAR or BmrH or &{orErR-.-,.___..**.* ,
nalntir l tnon+!:

tr, l$E flc/ii{lr

:tr, I.IAME
-F.lst da-Ee
Tdbi, (middle) nama ]laflter.S:_t
2. AonRsss
ltLr 5b a.u.1 t{ l]aatc {secr'raarej

!l
3" RclATroNsah m Cliir-D 4" DATI
',,',' 5"
bjgDature.

S, CMtrGXOATE
(To be sigladb! Alsistoni
Chlef of ,rubiocarhn and
c1ufikriigned bt Cllief of locati,2p*+1
4 R egistratioo dssjstatrt fofi
Name olsu bJocati , hueby certify that I have linowiedge ot
persooal derails offte u]o
c6. d na oed in tbe a bove ap plication ol)
aDd that, to tl.re best ofmy koo$redge,
the IacE given are n_ue
uate
Sigr.1 ed by RA
Countersjgued by"Sllq

D, T'OR USE OF'DISIIiCT

R.EGISIRAN
Fee of I(Sh."..--,"-"-.,,..,.i--__*_.pard.
R.efer to Cash Receipt IiTo.
Date.--...--.-.,---.**...
"---* -",

"n,'i"," ho r'nlicr ble.

n$lJ
ceni6c0te from Assjstant Cbief ls not
obtoinablei a-tanrls.nnt
varl'nrrrtrr .errjticat( or
orclioicai
cl r'n!d or doc!.rt/mrd$,Jrc
nrcdur-c.d 'e't/ncal( s.crlificare stou.rc be

CPr(
 c-P l38B
REPUBLIC OF KENYA

APPLICATION FOR LATE REGISTRATION ()F'BIRTH

SIIPPLEMENTARY QTJESTTONNAIRE

Supplementary inicrmation to b€ submitted in r€spe.t ofapplicants ctaiming to b€ born in Kenya.

l. (a) Full Names:

(b) Date and Place of Birth: ...,,-........

(c) Narn€ ofF
(d) Fathefs Date and Place ofBirth:
(e) Name and Maiden Name of Mother :

(0 Mothet's Date a.od Placa of Birth :

2. (a) Pres€Bt Resfttctrce

(b) Locatioo (or vr.ard in Towns):

(c) Name ofChief:
(d) Nerlle of Sub-Chief: .-...-.-,.-,.....-.
3. Supportirg DoeulE@ls
(a) ldentity Card No. : ..,--....-.-------.--
(b) Det2ils ofall Psssports Held by F

(c) Details of all Passports Held by Moth€r:

4. Ce!'ti$cate by Ass -Chief

I hereby ceftiry ftat I have made enquiries loc€lly and I have che.&,ed and found the above
particu.lars to be corect.

SuLLocation
Ass -Chiel-(Sigad$e)

5. Certtficete by Cbid

I hercby certit fiat I have checked with the tocal elders strd fird the above psrticuiars to be cor€ct.

Locstion
Chief-(Signature)
lJate

6. Certilicrte by Divilioarl Distrlct Ofiicer

I h€re by cediry that I have ch€k€d with locaion Chiefand fouad the above particulars
to be corrEc-t .

Divisiofls

D i$ tr ic! Ofrc e r- (Sig,stare)

Pe 1 ot2
 G.P I38B
REPIT'BLIC OF KE}.IYA

APPLICATION FOR LATE REGTSTR,ATION OF BTRTH

SUPPLEMENTAR.Y QUESNONNAIX.E

?- Certificde by District ComDissioner

I llave checked this application and I am satisfied that the applicant was bora in Kenya-

l)islrict

f)ak:
Districl Corlr&issiorgt (Si+7,atare)
NOTES FOR GUIDANC.E OF OFFTCERS MAKING CERTIFrcATES

i) Applicarts shoDld be askei lo ptaduce probf of their own and their parents birth wtricfi mry be in tbe form of Birth Certif-
cat45 or er(trac{E from Churcl or Corrununit, Registers.

(ii) The applicants should bring with them the old persons who have personal knowledge ofthe applicant's and his parcnts' birth.

(iii) A.ppticants should also be examined on {4ir knowledge of the Suehiii language and l,o{al history.

'a

FE2 ol2