BIRTH REGISTRATION FORM
Applicant's Name:* Can't be blank Mobile No :* Can't be blank
Child's Date of Birth* Can't be blank Child's Gender:
Mother's Name:* Can't be blank Father's Name:* Can't be blank
Birth Place* Address :
Child Name : Can't be blank Place where Mother Resides:* Can't be blank
Address* District Can't be blank
State* Can't be blank Religion
Mother Education* Mother Occupation*
Father's Education* Father's Occupation*
Mother's Age At Marriage* Can't be blank Mother's Age At Delivery* Can't be blank
Total Number of Living Children* Assistance Provided By *
Procedure of Delivery* Weight of Child (kg.)* Not a Valid wait Can't be blank
Pregnancy Period (Weeks)* Not a Valid value Can't be blank Enter Image Text