AGARTALA MUNICIPAL COUNCIL AGARTALA FORM OF APPLICATION FOR REGISTRATION OF BIRTH AND ISSUANCE CERTIFICATE AS PER BIRTH AND DEATH REGISTRATION ACT,1969 1. Name of the Child (in block letter) :- 2. Sex :- 3. Place of birth :- 4. Date of birth :- 5. Name of parents (a) Father's name :- (b) Mother's name :- 6. Nationality :- 7. Permanent address :- Signature of the applicant (Father/mother) Date____________________ 1. Documents to be enclosed duly attested by the Gazetted Officer. 2. Discharge certificate from the Hospital/Nursing Home with attested copy. 3. Certificate of birth from the Recognized medical Practitioner along affidavit from the Executive Magistrate (in case of Home delivery) 4. Attested copy of the citizenship certificate/Ration card/Voter/Service identity card of Govt. service of the parents . (FOR OFFICIAL USE ONLY) 1. Scrutinized the enclosed documents with filled in column above and found correct. Signature of the receiving clerk. 2. Prescribed fee deposited. a. Amount______________ b. Chalan receipt No._________ c. Date____________ Rechecked & signed by the Dealing Assistant 3. Recommendation for the Registration and issuing certificate .Yes/No. 4. Registration No _______________ dated______________Block No. _____________ and the certificate may be signed. (Dealing Assistant) Section-incharge (P.H. Section) Agartala Municipal Council ORDER OF THE ISSUANCE OFFICER Health Officer Registrar Birth & Death Agartala Municipal Council
