BIRTH CERTIFICATE WORKSHEET - Download as PDF by khu11116

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									                                                   BIRTH CERTIFICATE WORKSHEET
                                                                INSTRUCTIONS ON HOW TO FILL OUT:
                                           1)     PARENTS SHOULD COMPLETE ALL BLANKS AND SUBMIT TO BIRTH REGISTRATION.
                                                                       2) PRINT ALL ENTRIES.
                                                               *ALL BLANKS MUST BE COMPLETED
[1] NAME OF CHILD IN FULL (First, Middle, Last)                                                                                          [2] SEX (Check the right box)

                                                                                                                                        Male          Female

[3] DATE OF BIRTH (Month, Day, Year)    [4] HOUR:__________             [5] PLACE OF BIRTH (City, State, Country)

                                                AM             PM


                                  THE FOLLOWING ITEMS MUST BE COMPLETED BY BOTH MOTHER AND FATHER
                   FATHER                                                     ITEM                                                     MOTHER

                                                                       [6] FULL NAME
                                                                (Include Mother’s Maiden Name)

                                                                      [7] DATE OF BIRTH
                                                                       (Month, Day, Year)

                                                                      8] PLACE OF BIRTH
                                                                       (City, State, Country)

                                                                  [9] PRESENT ADDRESS
                                                              *House Address, Not Mailing Address
                                                                      (Street, City, State)

                                                              [10] ADDRESS IN UNITED STATES
                                                                      (Street, City, State)

                                                            [11] EVIDENCE OF U.S. CITIZENSHIP
                                                              (IF ALIEN, SHOW NATIONALITY)

                                                      [12] PRECISE PERIODS OF PHYSICAL PRESENCE
                                                                      IN UNITED STATES
                                                        (Month and year you were first present in th U.S. to
                                                       month and year you left to go overseas for more than 1
                                                             year with the military or as a dependent.)


                                                      [13] PRECISE PERIODS ABROAD IN U. S. ARMED
                                                            FORCES, IN OTHER U. S. GOVERNMENT
                                                              EMPLOYMENT, WITH QUALIFYING
                                                           INTERNATIONAL ORGANIZATION, OR AS
                                                                DEPENDENT OF SUCH PERSON
                                                         i.e Month and year you were present overseas and
                                                            month and year you left to go back to the U.S


                                                              [14] PREVIOUS MARRIAGES
                                                       (SHOW DATE AND MANNER OF TERMINATION
                                                                       OF ALL)
 [15] DATE AND PLACE OF PRESENT MARRIAGE (Month, Day, Year – City, State, Country)


              THIS SECTION CONTAINS OTHER IMPORTANT INFORMATION NEEDED IN PROCESSING OF YOUR BIRTH REGISTRATION

 BABY’S LENGTH: ________________________________________ Inches                    ATTENDING PHYSICIAN: _____________________________________________


 BABY’S WEIGHT __________________________ Lbs. _________________ oz.               NUMBER OF CHILDREN BY THIS MARRIAGE (Including Present): ___________

  SPONSOR’S RANK/RATE: _________________              BRANCH OF SERVICE: _________________                           DUTY PHONE: _______________________________


 HM/CELL PHONE:____________________________           ACCOMPANIED TOUR ?                        Yes             No         (Check Appropriate Box)



 MAILING ADDRESS: __________________________________________________________________                     REMARKS: ________________________________________

								
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