Form B3 REPUBLIC OF KENYA DEPARTMENT OF THE REGISTRAR-GENERAL APPLICATION FOR LATE REGISTRATION OF A BIRTH ‘Please complete his and return it together withthe correct ee tothe Civil Registrar in your Sub-ounty A.INFORMATION REGARDING THE CHILD 1. NAME. ses a Fist Name “rial mile) name Father's name (surname) 2.DATEOF BIRTH. sen SEX: Maleemalet Bay Mon ‘Year 3, PLACEOF BIRTH. a ‘ij and Suloaton ost and own District, 4. NAMEOF FATHER ire Name ‘Tribal (mide) name Fathers name (surname) 5.NAMEOF MOTHER. ——— a ai Fist Name “Tribal (mide) ame ‘Mother's ame (surname) 6. YEAR OF BIRTH OF MOTHER B.APPLICANT 1. NAME. sen : Fist Name “hibal (mide) name Father's mame (surname) 2. ADDRESS. - ‘Mobile Phone No, 3 RELATIONSHIP TO CHILD. 4.DATE : Signature (C.CERTIFICATE (Tobe signed by Assisunt Chief of Sub-locton and coomersigned by Chie of Loation**) 1. Registtion Assist for hereby cei that Ihave knowledge ofthe personal ‘Name of Sub-location euils ofthe child named inthe above aplication and tha, to thebestof my knowledge, the facts given ar tre. Dae Signed by RA. Countersigned by SRA. D. FOR USE BY CIVIL REGISTRAR AT SUB-COUNTY Feo of Ksh o paid Refer to Cash Receipt No. Signature. "Delete ingpliable. ‘PI certfintefrom Assistant Chie i not obtainable, «bepimal ete oe ical card or doctor smidwife's certificate shouldbe produced.