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Official Emblem
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 ....
Local registrar
(Official seal affixed)

Certified correct translation