NELLORE MUNICIPAL CORPORATION

APPLICATION FOR INCLUSION OF CHILD NAME IN THE BIRTH CERTIFICATE

REGISTRATION OF CHILD NAME

From To

Name : The Registrar of Birth and Death

Address : Municipal Corporation, Nellore

Mobile :

Sir,

I ………………………………………………………… S/o W/o……………………………………………

aged about ……… years , working as ………………………………………………………………………

(Designation & office Address), residing at …………………………………………………………..

(Complete address with Door No) declare that my wife delivered Male / Female

child at ………………………………………………………………………………(Actual place of birth)

on ………………………………..(Date of Birth).

Hence, we request to include our child name as …………………………………………

………………………………. In the Birth Register.

Signature & Signature &

Name of the Father of the child Name of the Mother of the child
 DECLARATION OF NAME ENTRY

Sri/Smt……………………………………………………………………………………………………………………….
S/o, W/o. …………………………………………………………………... aged about………… years working
as …………………………………………………………………………..(Designation & office Address) residing
at ………………………………………………………………………………………………………….. do herby solemnly
declare and affirm that:

Sri/Smt……………………………………………………………… is my wife/husband that male/

female children born to us, the particulars of whom are given below:
Order Sex Name of the child Date of Birth Place of
of of (FULL NAME IN CAPITAL LETTERS ) Birth(Hospital/
Birth the House Address
child

That the male/female child born to upon ………………………………..(Date of Birth of the

child) had been named as …………………………………………………………………….(CAPITAL LETTERS)
and the same may be entered in Birth register.

That the above particulars as declared by me/us are and correct and that no
corrections or omission or additions shall be requested by us or our relatives regarding
the name, now entered in the records.

Signature of the Father Signature of the Mother

Dated: Dated:
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The above particulars as declared by Sri/Smt…………………………………………………………

are true and correct to the best of my knowledge and better and signed before me

Station: GAZETTED OFFICER

Dated : (With seal)
Name of the Officer