App-Birth Certificate _28627 - by l1ve65

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 APPLICATION FOR A BIRTH CERTIFICATE
 To the Registration Officer having custody of the Register

 Please provide as many details as possible filling the boxes below. The questions marked *
 must be completed. Please print within the boxes using BLOCK CAPITALS AND BLACK
 INK only.


1. Contact Details to be completed by the person applying for the certificate

 Applicant Full name (first name followed by surname *                                      Title *



 First line of address *



 Rest of address


                                                                       Post code*

                                                                                        -
 Daytime telephone number*                                      Mobile number



 E-mail address




2. Purpose of Certificate
It would help us if you would state the purpose for which the certificate is required




3. Are you applying for your own certificate?                   Yes       No
If not, please state your relationship to the person to whom the certificate relates.




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 APPLICATION FOR A BIRTH CERTIFICATE
   ENV-BC Site Inspection
4. Details of certificate required

 Full name at Birth (Forename(s)*



 Surname*



 Date of Birth (DD / MM / YYYY)*
         /          /
 Place of Birth* (full address or name of hospital)




 Rest of address


                                                                       Post code

                                                                                          -

 Father's full name (Forename(s)*



 Surname*



 Mother's full name (Forename(s)*



 Surname*




5. Requirements
 Standard Birth Certificate £                    .      I require           standard birth certificate(s)
                                                                 (Number)

 Short Birth Certificate           £             .       I require          short birth certificate(s)
                                                                 (Number)


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 APPLICATION FOR A BIRTH CERTIFICATE
6. Payment

 Remittance enclosed (Postal Applications Only)            £                 .
 Signature
                                                           Date of signature (DD / MM / YYYY)

                                                                     /           /
 Print Name                                            Please make cheque payable to Croydon Council,
                                                       and ensure that the cheque guarantee card
                                                       number and expiry date are written on the reverse
                                                       of the cheque.
                                                       Please enclose a stamped addressed envelope.

 The London Borough of Croydon will only use the personal information you supply on this form
 for the purpose of your application, and in accordance with the Data Protection Act 1998 and the
 Council's Privacy Policy which applies to the websites of the London Borough of Croydon.
 Copies of this Privacy Policy may be found at: http://www.croydon.gov.uk/privacypolicy

                           The completed form should be sent
                           to:
                                Croydon Register Office
                                Mint Walk
                                Croydon
                                CR0 1EA




For Register Office Use Only
 Register number                                    Entry number




 Certificate number                                            Date of issue (DD / MM / YYYY)
                                                                         /           /

For Office Use Only

   Cheque         Postal Order   £             .                    Unsigned             Undated



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