B12'

+egistry o &irths! Deaths and Marriages! ,estern -ustralia ./. St Georges Terrace! Perth ,T0(1 .233 234 35.

(Western Australia ONLY)

BIRTH CERTIFICATE APPLICATION FORM

Payme n t details over the page you MUST return pages 1 and 2 if applying via
Fees including standard postal delivery effective 1 July 2009 Subject to change without further notice o !S" is payable on these certificates

"I T# C% TI-ICAT% "I T# C% TI-ICAT%

)/educed 3ee,

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.//0 11 .210 1 1 .2/0 1 1

#nly applies where the full registration number is supplied by you and the birth is $ore than %& years old' #therwise full fee applies'

(n addition to any other fee' Does not include )*press +ost'

Urgent fee not payable for co$puterised certificates if applied in person at the +erth ,egistry #ffice or certain ,egional -ourthouses' See Locations & Links webpage' For eligibility see the Birth certificate access policy on the Births webpage'

mail

Identification and Certificate Access

See page 2 or visit www.bdm.dotag.wa.gov.au

e!uiremen ts

Processing Times for Mailed Certificate Applications

Standard Urgent
44(

- Please allow up to 2 working days plus postal delivery time - Processed within 24 hours of receipt plus postal delivery time

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Surname (at birth) Gi en name(s) !ate "# $irt% Pla'e "# $irt% in Western Australia Fat%er(s name M"t%er(s name

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Day Month Year

Please P I(T clearly

AB ! "# $%& $'%

Surname

Present a&e

Male

Female

Suburb / Town

Given name(s)

Maiden surname

Given name(s)

)please see ne*t page for access conditions and identification

APP&ICA(T)S $%TAI&S
re+uirements, Full name P"stal a))ress
Your Relationship to the person whose certificate you are requesting

Suburb State Postcode

e.g. sel ! mother

!a*time +%"ne num$er

Email a))ress Reas"n re,uire)

Pass"ort (egal

&an% re'uirements

Driver#s licence Marriage

$entrelin% (ost

)amily history *ther $eclara tion * - declare that the information - have provided is true and correct. - understand that the .A /egistry of Births0 1eaths and 2arriages may make en+uiries with any organisation or individual to verify the information provided with this application.

SI+(ATU % ,- APP&ICA(T
OFFICE -SE ONLY

Signature must be completed

Page ' of $

LIST 1 (with photo): Drivers Licence

Passport

Proof of Age

Firearms Licence

Defence/police

Citizenship Cert

Learners permit car !D "ef# 666666666666666666666...6 LIST 2 # $irth Cert%Aust& Citizen papers Cr/De'it Car !D "ef# 666666666666666666666...6 LIST 3 (current address): $an* +tatement 0ther "ates notice - ucational report !D "ef: 666666666666666666666...6 (ealth )e icare Centrelin* +tu ent car ,ravel Doc

66666666666666666666666..
)otor .ehicle "ego /tility account "ental agreement
If ID provided from Lists 2 and 3, one ID must contain a signature

66666666666666666

66666666666666666

!nitial !D sighte .66....66.....

/egistry of Births 1eaths and 2arriages0 .estern Australia

B12'

Page 2 of $

"I T# C% TI-ICAT% APP&ICATI,( I(ST UCTI,(S

#,4 T, APP&3
POST the co$pleted for$ 6pages 1 7 28 to9 ,egistry of :irths; 2eaths 7 3arriages +# :o* %%20 -loisters S.uare +),"< => ?@&0 OR BRI ! the co$pleted for$ 6pages 1 7 28 to9 ,egistry of :irths; 2eaths 7 3arriages Aevel 10; 1B1 St !eorges "errace +erth between @'C0 a$ D B'C0 p$; 3onday to Friday #a$e% applications &ill not be accepte%

5 4ick the forms of identification that are supporting

your application

&IST 1 - 5vidence of link between photo 6 signature

-ustralian %ri0er1s licence 6with photo8 -ustralian passport 6with photo8

ote"

firearm1s licence 6with photo8 -ustralian

Defence #orce2Police ID car% 6with photo8

4#, CA( APP&3 -,

A C% TI-ICAT%

-ustralian 3iti4enship 3ertificate with evidence of residence status 6with photo8 O0er '5 or Proof of -ge I%entity car% 6with photo8 -ustralian learner %ri0er1s permit car% 6with photo8

Birth certificates are available to the registered person 61? years of age or over8 or a parent na$ed in the birth certificate' (f the certificate relates to a person other than yourself and you do not .ualify under the ,egistryEs -ertificate >ccess +olicy; you $ust provide the written consent or authority fro$ a person entitled to the certificate and you $ust also provide identification for yourself an% the person for who$ you are acting' (nfor$ation regarding the ,egistryEs -ertificate >ccess policy is located on our website at www'bd$'dotag'wa'gov'au; or telephone the ,egistry on '()) ()* )+''

&IST 2 - 5vidence of operating in the community

Debit or 3re%it car% 6one or the other; not both8 issued by a financial institution Document of i%entity issued by the +assport #ffice 6ntitlement car% issued by the -o$$onwealth or State !overn$ent 6-entrelinG; <ealth -are card; 4eterans >ffairs card etc8 #ull Birth certificate issued in >ustralia 6birth e*tracts not accepted8 ,e%icare car% aturalisation7 citi4enship or immigration papers issued by 2ept of ($$igration 7 :order +rotection 62(:+8 O0erseas passport with current >ustralian )ntry +er$it Security guar% or cro&% control licence 6>ustralian8 Stu%ent i%entity %ocument or statement of enrolment issued by an educational institution; including "ertiary6should include photo and/or signature8 8orking &ith chil%ren car%

Privacy Considera ti ons and Personal

ecords

-ertificates held by the ,egistry contain sensitive and personal infor$ation' <owever the ,egistry allows unrestricted access for birth certificates which occurred $ore than 100 years ago'

I$%(TI-ICATI,(

%'UI %M%(TS

=hen applying for a =estern >ustralian certificate; evidence of your identity $ust be provided' 5ou ,UST provide at least three for$s of identification9

#ne docu$ent fro$ each Aist 61; 2 an% C8' >t least one containing a photographF or #ne fro$ Aist 1 and two fro$ Aist 2' >t least one containing a photograph; or "wo fro$ Aist 2 and one fro$ Aist C' >t least one containing a signature'

>ll for$s of identification ,UST be current' 2ocu$ents fro$ Aist C ,UST show your current resi%ential a%%ress' :anG state$ents; utility accounts or rates notices ,UST have been issue% &ithin the last si$ months '

&IST 2 7 5vidence of current residential address

Dri0er1s licence rene&al notice #inancial institution statement less than si* $onths old ,otor 0ehicle registration Property lease or tenancy agreement Shire2&ater rates notice School or other e%ucational report or certificate less than twelve $onths old Utility account less than si* $onths old )gas0 electricity0 home phone0 etc,

C% TI-ICATI,(

%'UI %M%(TS

-pplying in person . original docu$ents $ust be provided' -pplying by post D please send clear certifie% photocopies of your identification docu$ents with your application' +hotocopies of identification will only be accepted if they are certifie% by a /ualifie% &itness as being Htrue copiesI of the original docu$ents' See page C for Certifying documents'

-U T#%

I(-, MATI,(

For further infor$ation; please visit our website at www'bd$'dotag'wa'gov'au or call 1C00 C0& 021 between @'C0 a$ and B'C0 p$; 3onday to Friday'

PA3M%(T $%TAI&S
form

If applying for more than one certificate only complete payment details on one

Applicant)s -ull (ame

2ebit $y 3aster-ard or 4isa for 1

)nclosed is a che.ue/$oney order0 for 1 OR

0 5our che.ue or $oney order should be $ade payable to the Registry of Births, Deaths and Marriages -ard o )*piry 2ate Page ( of $

a$e of -ardholder

Signature of cardholder

/egistry of Births 1eaths and 2arriages0 .estern Australia

4#, CA( C% TI-3 $,CUM%(TS6

4his page is 84 to be forwarded to the /egistry of Births0 1eaths and 2arriages

Certifying documen ts 7photocopies of identifica tion8

:efore certifying a docu$ent; ensure that the copy to be certified is an identical copy of the original' Suggested wording for the certification is as follows9 I certify that this appears to be a true copy of the document produced to me on < date > Signature Name Qualification (eg JP, Pharmacist)

Aist of persons who can -ertify 2ocu$ents9 >cade$ic 6postDsecondary institution8 >ccountant >rchitect >ustralian -onsular #fficer >ustralian 2iplo$atic #fficer :ailiff :anG 3anager -hartered secretary -he$ist -hiropractor -o$pany auditor or li.uidator -ourt officer 6Judge; $aster; $agistrate; registrar or clerG8 2efence Force officer 6-o$$issioned; =arrant or -# with & years continuous service8 2entist 2octor )ngineer (ndustrial organisation secretary (nsurance broGer Justice of the +eace Aawyer Aocal govern$ent -)# or deputy -)# Aocal govern$ent councillor
Page 4 of $

Aoss adjuster 3arriage -elebrant 3e$ber of +arlia$ent 6State or -o$$onwealth8 3inister of religion urse #pto$etrist +atent >ttorney +hysiotherapist +odiatrist +olice officer +ost #ffice $anager +sychologist +ublic Servant 6State or -o$$onwealth8 +ublic otary

,eal )state agent Settle$ent agent Sheriff or deputy Sheriff Surveyor "eacher "ribunal #fficer 4eterinary surgeon

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