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(Translation)

Registration of Divorce
Khor Ror.6

Registration Office
Particulars 1. Name 2. !entification No. ". #ate of $irth %. Registration of Marriage Reg. Office Reg. No. #ate Male

Province
Female

&. 'ignatures of a((licants

6. 'ignatures of )itnesses 1. ******************* *****.. 2. ******************* *****.. +. Registration Reg. No. #ate,Month ,-ear 'ignature of registrar .!!en!um Time hrs.