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Translation

Official Emblem
No......................
Form : Chor 5

Certificate of surname change registration

Identification No. ..
Residing at house No. Road, Alley or Lane :.. Village No.
..Sub-District, District,
Fathers name :.. Mothers name :.
Has requested to change the surname to be : .
In case of:
The registrar has granted permission according to the application No,Date
Therefore, this certificate is issued as evidence.

District Office of
Issued on ....
-signature(.)
Local registrar
(Official seal affixed)

Certified correct translation