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Adobe Scan Feb 11, 2024

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86 views

Adobe Scan Feb 11, 2024

Uploaded by

gurpreetnijjar51
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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~HdB 'd

Department of Health and Family Welfare / f l @ 3 " " " 3 ~ ~ ~

Issuance of Birth Certificate/Non Availability Certificate / nc')}f -ei 11a8 fc;;~c!' I ~ Aaelfc:~c ~ crao ffirr
Government Fee: Rs. 1o per copy and Rs. 5 per year for search of records
For Official Use Only/ ~ ~ ~
Facilitation Ch arges: Rs 50
Application Number/ »loiff nira: I Date of Application / »loiff -el llf3t I
Name of Block & Tehsil /w.r/ 3'fulira -e, i'i"

Part- 1 Applicant Details 1. Fields marked with asterisk(*) are mandatory/ ~~3~ (*)~ c l ' B<J
2. Fill the details under this section In English

Personal Data of Applicant / ~ e> ~ ~


Note : These details are of person who is applying on behalf of Beneficiary I fE.T ~~~~~;:I
fu' ~
3'd'i; 3' l\@i'IT ~ ~
1. Name•
2. Father Name•
3. Mother's Name *
fJ(-I P.IfJ O!i A Ki-WI,
4. Date of Birth *
Age:
5. Gender •
Male □ Female B Transgender
6. Marital Status * Separated □ Widowed □
Married □ Unmarried G:3 Divorced □
7. Spouse Name • (Only in case of Married, Separated and Widowed)
8. Contact Number * 9 'f I 5 ?... '.l. '2. 3 0 =,-- Email ID:
9. Region Rural 0 Urban D
10. Permanent Address• V / f-J l. pU I< 11 fl-JU fa.. LA

11. PIN Code* Ii '14 c, 2 12. Sub DistricUTehsii* PHACn ~ARI+


13. District * kA U fq TH f-7L/I- 14. State*
15. Village {In case of Rural Region onlyt
~ Correspondence address same as permanent address

16. Address of Correspondence

17. P IN Code * 18. Sub District


19. District * 20. State*
21. Village (In case of Rural Region only)*

Part - 2 Service Details

Applicant Details/ ~ ' e " ~

22. Applicant's Relation with beneficiary I fu?icl'o c' ~ ?i"8'


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23. fu?icl'o ~ l'i'H ' ( ~ i.rrr-at ~ ~)

-~ , o-({Y, L/~ (;{"


l=f'i;ti?\) ~~ ~ .!~'R\
Last Rev: Jul 2019 © Government of Punjab Page 1 of3
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