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Bt-196

DEPARTMENT HOME AFFAIRS

RE PUBLIC OF SOUTH AFRICA

APPLICATIONFOR AUTHORITYIN TERMSOF SECTION26

OF T H E B IR T H SAND DEATHSREGISTRATION
ACT, 1992,
T O A SSUMEANOTHERSURNAM E

I herebyapplyfor authorityto assumethe surname

and furnishthe followingreasonfor my application.

PARTICULARSOF APPLICANT:
Presentsurname

Forenamesin full

ldentitynumber
f-lTf-t]-t fr-lTr [T-[l Dateof
birthfT-l-Tl U tI
Place of birth

Postaladdress

Postarcode
t-T-l-T-]
Telephonenumber Telephonecode

|a|sowishtoinctuoefiiil}'ii|n,whoseparticu|arsofbirthareasfo||ows:
WIFE:
Maidenname

ldentitynumber
rT]-f-t-Tr [r-Tt-r [I-T]
Forenamesin full

CHILDREN:

Forenamesin full and surname Date of birth Place of birth ldentitynumber/

Birth entry number

Consentof wife (if applicable)

Signature of applicant Signature of wife

Date
FOR DEPARTMENTAL USE