PDF-Birth Date

NameTodays Date Your answers to the following questions will help us understand your medical history Please fill out as much information as possible If you cannot answer a question or feel uncomfor. Age Weeks Birth Comment AGE MONTHS 10 11 12 13 14 15 16 17 90 95 100 cm cm 100 lb 16 18 20 22 24 26 28 30 32 34 36 38 40 45 50 55 60 65 70 75 80 90 95 85 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 in in 41 40 39 Signature Date Signed Request will not be processed without the signature and ID of the applicant full fees and established eligibility If Child less than 2 yrs Name of Hospital or Midwife Division of Vital Records Phone 1000 NE 10 th Street PO B Age Weeks Birth Comment AGE MONTHS 10 11 12 13 14 15 16 17 90 95 100 cm cm 100 lb 16 18 20 22 24 26 28 30 32 34 36 38 95 90 75 50 25 10 40 45 50 55 60 65 70 75 80 90 95 85 95 90 75 50 25 10 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Age Weeks Birth Comment AGE MONTHS 10 11 12 13 14 15 16 17 90 95 100 cm cm 100 lb 16 18 20 22 24 26 28 30 32 34 36 38 40 45 50 55 60 65 70 75 80 90 95 85 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 in in 41 40 39 Age Weeks Birth Comment AGE MONTHS 10 11 12 13 14 15 16 17 90 95 100 cm cm 100 lb 16 18 20 22 24 26 28 30 32 34 36 38 40 45 50 55 60 65 70 75 80 90 95 85 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 in in 41 40 39 Age Weeks Birth Comment AGE MONTHS 10 11 12 13 14 15 16 17 90 95 100 cm cm 100 lb 16 18 20 22 24 26 28 30 32 34 36 38 95 90 75 50 25 10 40 45 50 55 60 65 70 75 80 90 95 85 95 90 75 50 25 10 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Amani Mvomero . Names of Clients. .. Name:Abdala Alfan. Date of birth. :. Ward. : Mvomero. District. : Mvomero. Region. : morogoro. Type of disability. : Mental Disability. Name:Shabani Masudi. Date of birth. 3: _________________________________________________________ CHILD 4: ______________________________________________________________ NAME DATE OF BIRTH ___________________________________ ThMnk you in MdvMnce for requesting Mn MpplicMtion to become M citizen of the United Fherokee Ani - Yun - WiyM NMtionB Fitizenship in the United Fherokee Ani - Yun - WiyM NMtion is open to Mny perso RET-45 (7/19) 10 Corporate Woods Drive, Albany, NY 12211-2395 PROOF OF DATE OF BIRTH When applicable, NYSTRS may notify you that we require proof of your (or your beneficiary’s) date of birth. HEALTH COVERAGE ENROLLMENT FORM EMPLOYEE/PARTICIPANT INFORMATION SOCIAL SECURITY NUMBER CITY MALE FEMALE HOME PHONE SPOUSE INFORMATION IF N Name Date of Birth// Place of Birth Sex Male Female Language Spoken at Home Name of Mother Address Name of Father Address Occupation of Mother Occupation of Father FAMILY HISTORY about live birth characteristic in the every . country. 1—date of occurrence . . yes. 2—Date of registration . . APPLICA DA BIR TH IN SCHOOL RECORDS TIFICA TE OF QUALIFICA I) G.O(Rt) No. 853/2011/G.Edn. (G) Dt. 1.03.2011 (GEdn.) Dept. II) G.O. (Rt)No. 2281/2011/G. Edn. Dt. 18.06.11G.Edn. (G) Dept(To be r