Certificate replacement by HqwsgMcU

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									QUEENSLAND FLOODS – JANUARY 2011
BIRTH, MARRIAGE OR CHANGE OF NAME CERTIFICATE
Registry of Births, Deaths & Marriages
PO Box 15188, City East, QLD, 4002
Ph: 1300 366 430



        Certificates issued by all other Australian States and Territories can also be obtained by using this form.

Please print clearly
                            Which type of certificate do you require? (please tick)
Adult one
                                    Birth Certificate                    Marriage Certificate                 Change of Name

Current surname                                                                 Given name(s)

Registered
                                                                                Given name(s)
surname
Daytime Contact
                                                                                Email address
phone No.
Address                                                                                                                                          Postcode
(to mail certificate)
*Note: If you do not have an address that certificates may be mailed to, the Registry will contact you to establish an alternative.

                                    Day       Month         Year                                                Day        Month          Year
                                                                                Date of name
Date of birth                             /            /                                                              /               /
                                                                                change (if any)
Place of birth
                                                                                State of birth
(Town or suburb)
                                                                                Father’s given
Father’s surname
                                                                                name(s)
Mother’s maiden                                                                 Mother’s given
surname                                                                         name(s)


Please complete the details below if you are applying for a replacement Marriage Certificate
                                    Day       Month         Year                                                          Town or Suburb             State
                                                                                Place of
Date of marriage                          /            /                        marriage
                                                                                Groom’s given
Groom’s surname
                                                                                name(s)
Bride’s surname                                                                 Bride’s given
(prior to marriage)                                                             name(s)



                            Which type of certificate do you require? (please tick)
Adult two
                                    Birth Certificate                    Change of Name

Registered
                                                                                Given name(s)
surname
                                    Day       Month         Year                                                Day        Month          Year
                                                                                Date of name
Date of birth                             /            /                                                              /               /
                                                                                change (if any)
Place of birth
                                                                                State of birth
(Town or suburb)
                                                                                Father’s given
Father’s surname
                                                                                name(s)
Mother’s maiden                                                                 Mother’s given
surname                                                                         name(s)
                                                                           Page 2

QUEENSLAND FLOODS – JANUARY 2011
Please print clearly
Child one            Birth Certificate

                                   Day          Month           Year                                              Town or Suburb          State
Date of birth                             /             /                   Place of birth

Registered
                                                                            Given name(s)
surname


Child two            Birth Certificate

                                   Day          Month           Year                                              Town or Suburb          State
Date of birth                             /             /                   Place of birth

Registered
                                                                            Given name(s)
surname


Child three          Birth Certificate

                                   Day          Month           Year                                              Town or Suburb          State
Date of birth                             /             /                   Place of birth

Registered
                                                                            Given name(s)
surname

Note: If you have more than three children that need a replacement certificate, attach a separate sheet with their details.


 If you have any identification documents please complete:

 Driver’s licence number                                                            & State of issue

 Passport number

 Medicare card number


 Other – Please specify



I declare that:
     the information provided in this form is true and correct.
     the certificates being requested, having previously been in my possession, have now been destroyed due to flooding.

I understand that:
     giving false and misleading information is a serious offence.
     by providing these details I consent to the use and disclosure of information to assist in obtaining the requested
        documents.

Adult one signature                                         Date            Adult two signature (if applicable)                    Date

                                                            /          /                                                           /   /



                             Office use only:
 POI sighted

 Name:                                             Date:

 Signature:


 BDM Ref:                                          Date:

								
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