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Application Form - Livebirth

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Republic of the Philippines

BARANGAY MAPULANG LUPA


Valenzuela City

APPLICATION FOR BARANGAY CLEARANCE


(FOR LIVE BIRTH)

CLEARANCE No.____________

DATE: _____________________
NAME OF CHILD: _____________________________________________________________
(Last Name) (First Name) (Middle Name)

SEX: ______ Date of Birth: _____________ Place of Birth : ____________________________


MOTHER’S NAME: ____________________________________________________________
( Maiden) (First Name) (Middle Name) (Last Name)

RESIDENCE : _____________________________________ Age at the time of this birth:____


No. of Children
CITIZENSHIP : ____________________ Religion : _________________ Born Alive : _______
FATHER’S NAME:_____________________________________________________________
(First Name) (Middle Name) (Last Name)

CITIZENSHIP : ____________ Religion : ________________ Age at the time of this birth____


IF MARRIED, Date & Place of MARRIAGE OF PARENTS:
______________________________________________________________________________
BIRTH ATTENDANT:_______________________________ Occupation : ________________
NAME OF INFORMANT / APPLICANT : ___________________ Relationship to the Child:_________

CTC NO. : _________________


ISSUED AT : _________________
ISSUED ON : _________________ ______________________________
AMOUNT : _________________ Applicant/s Signature

REMARKS : ________________________
___________________________________
___________________________________
___________________________________

______________________________
Reference / Neighbor’s Signature

Assisted By: APPROVED:

HELEN D.R. PABAYA Hon. FERNANDO C. FRANCISCO


Barangay Secretary Punong Barangay
Clerance. Rechelle Mae Dayal

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