C.F No.

17

Cost of Form Rs.2/-

No. Coimbatore Corporation Application for issue of Birth Certificate

Affix Re 1/- Court Fee Stamp

From

To The Commissioner, Coimbatore Corporation.

Sir, Sub : Application for Birth Certificate. I request you to issue ___________________________ copies of Birth Certificates to my male / female child, as per the particulars furnished below:

1. Name of the Child 2. Date of Birth 3. Sex [Male / Female] 4. Name of the Father 5. Name of the Mother 6. Place of birth, Name of Hospital / House (Full Address)

: : : : : :

7. Residential Address at the time of birth

Date: Place: Signature of the Applicant Cost of Form: Rs.2/Cost of Service: Rs.10/-

Note: Register the name of the child and get the Birth Certificate, with the name of the child.