1-D r 0031

MINISTRY OF H'O'ME AFFAIRS

D'EPAR. E -T 'OF' CIVIC AFFIRS

APPLICATION FOR THE LATE RE'GISTRATIO ,O'F A BIRTH

WARNING: rAE PENALTIE FOI~F'LSE STt\TEME T'WlLLFUl.t.Y MAD'E R - 1-1 S ~'1E! AS THOi -t: fOR PKRJR~·.

OMP'LETIN G TI-I E FORM,

A.

SLII"JHl111C: ,---~_,-~ __ ".,. ,_",.,,' ,. ",.," _' • '

F.ir~t nmn .~ in lull: ..... "_"" .. ",.,,. ,., ". M •••• '.", ..... '''.'' •• _~_,~ • ~,_-'" ...... , ••• , .. '' ••• , ••• '''.''_ •• _'_'--"-M"-_

D·',L'lC u r b ~ rt h: ._._. . __ ._,.,.".- " .. , .... ".,. ,." .".__________ illa~t:' cf birth. , .. _~~ . ~ __ '".~ ...... , ,.,' , .. , ..... , .... , __ ... __ .. _,.- ..... -

Country uf hirth .. __ ._ .. __ ".". " .. ,,_. ._.~ .. , ,_." .. _,,, , " .. ~ __ ~_. " _ __,_-_ " , "".,, -,--.--._, -_

Residential address: , " , .. , _ -~M- _~' _ ~~ Tet No,: _. .. , _, .,-"'."

I den! ity number: I II II II III I~ II I I I II II I 1

Was the child born in amarerniry home or hospital?

Ye D

B, ..

S ttl t e w h ethe r father is:

D,

A11ve

Dead D

His present residential address (if ali C): ,

____________ -M-.' __ ' ........ __

.......... , .. ,; _ .. _ _, __ .. _ "" .. " " .. _~~ ~ l'e-L No.: _, . __ . - " .. , , " .- .. '" __ .. ~ '"

Ff deceased. state dale: , __ . _. District of death: __ M , .. " , _, ,_._~.,_._._ .

S urn:;une: _ __ .. _. , , ,' ~~~

First names in full: " .. " _" .. ,,~, .. ,~ . .M •• " •• " ~~ • ~ " , _ .. , .. __ ._,_."' _~"" __ , .. ,

Date 01' birth: _._ ''''' " ".''' .. _ .. ~ __ . ~ __ M__ .w _ Place: of btrth: , _ "' .. , .. __ , ,~. __ ._ _-.~ .. ,_ ""'."

Country of birth: , .. "' , .. ,' " .. ~ .. _, . __ -M •• " ,

[demit)' number: I I I '1 I l .~ [ I I II III

~~. ~~ I"'I"'I~~I_.' 1.,I ••• , .... ~I~w .. ,~ ..... , ......... __ ... ___, .. _ ........... rl ..... rl_,~'" ,.,,,, •••

Citizenship at the time of chi Id's t apphcant's bmh: -M _~~ __ ~_~_M .. ' .. , ,_ .. _.-.M.M.- _ .. , .. ",

I r the father is not a Namibian ciuzcn. slate whether he is a permanent resident of the RepllbHc otNamibia:

Yet> D

No D

I f'ves, state Perrnanenl Residence Permit Number (not number of form)

... ~.'I"P •• ' •• ' .. "." •. 1 ..... __. .. _"1_.....,__,.., ............. ,...... ... ~=I'1 •• ,I.,I •• ,., .... ,I ......... _ .. , ... -'

and date '"_,'" ._.,_ ... " ... '_. ._

REPUB,LI'C OF' A1\lIBlA '(]ilh,i' ,tr) of How,e .-\.ffain)

PA N~ 352083

FOR OFFTClM. nsF.

ONLY

UIPW'\JTI:C P.·\}SPOR.T

D

L NAME
Surname II
First Name ~ 'PORT
i [ I I [-I
I I, ~ i I I I
i ~ J I I 0 l'llEV IOU S, RNAMECS

Surname at birth

LJ =r I,

(hhl:r N ames ~.I r changed)

2,.

P EIL'ONA.L 'I NFOR~\.f"<\ TIO~

Date 0 Birth .... 1 ---......,.,...-----11 1-[ _....JI L...I _---'

Y~"I \ti I!llb

Male! I- _I

Place of Birth I

~----~~-'~-TI----------~'l~-u~nt-~----~

00

Sex

Fcmal~l ... __ ----,

Marira1 Starns 0 0

D

Eye I

............ -

He~ghl.._[ _---'

Weignlf,- __ I Occupation .__ _

Res iden ual Andres So

."u :'Il"~ Town

II I L __.] '-1 ---, F-------, ..-------

Telephone _ _

A.l~.! ( f>fl~

Postal Address

.1. PREVIOUS NAMIBIAN P .... '\.sSFORT -Jn the ~a_S15 years has a Namibian passport been issued to your

4. Crrrl..lENSHEP - You must provide the documents below (Gl:rLified photocopies acceptable)

If you were horn outside Namihla

o

~ ~l. ~I ~

[hl(, ~'II"u.:-

~ ~ctltf,,~r~ tor ~~u .. r" h'r. '~I

r::::::J (I:rl III: He ,'I narnrr] '.'il.r um, ,;11

D c"rtl •• ('.I~r" .·t 11~~o\rLrIUU ur 1.lr'O~tlh;iI!lr~ III ~ cerr 1I,',,;I(,.d r'~"I',lr ililifi ,II lunh ~hl"'ld

0'

REPUiU .. U: O'F NAIMIBIA (Miln~SiIiry 'of Home Affa~,rs)

For official US!!!;

ReOOipl No; , . ".""".",,.

Amo.ul1t " "'" ."." ,," .. ,..

DoliI!'! _ ,_._. _ _- ...• ,

I S!grmluTti .. " -- .. -

FIQR: OFACIAL IJSE ONLY

p~ No: .•• ._ ~ ---.

Di:t1:a of ~I!! ~ ._ •••• ; •••• """,, •••

Dat.!! 01 exptry __ ~ .

ReF lfflld Lm:fJl _ " _ _._ __

011 .. __ - " -- ,,-- , , .. --

ErKk:w'.m 00 .. _ , ..

Dam ._ .... .... " .. ., , __ . , " ,. , .. .

APPUCATION IFOA (Indicate by meillns of a cross whale,ver ils appllicable)

NAMIBIAN P'ASSPORT D ENDOR,SEMENT D 'RIEN'EWAl

Q'F'FICIAL PASSPORT D EIME'RGENCY TRAVEL CEllnFllCATE D

D

A. P,ERSONAL PAIRTICUIJ\IRS (In blot::k letters)l

Surl:tol'lID

TO SE COMPLET£D BY An A PPUCANTS

Se;~

D Mall') OIF-et]l.;!Ll1!

(Stn:t!!' OOLll'ltry I

'P!nm oi birlP'l

ro.,.,n " ,., .. " "" ".... . _ .. -- ",_ , " ---- ..

~:i " .... ", .. , ..•. ,.", .. ""., r II ••• u ••••••• ~ .. " ... ~ "' ~" ~ ...... • ............ • ...... ·-~I~ ... •

Fersonnl daacnpnon

!ll3lg11L ...... _ .

Cot<Jur of ooyos_ ..

Single

'0

o

I I I ~ I II I I I I i ~ 1 !

o

Nam€l oj i'lu~ 01 ~e .. " " _ , .. , .. ,.. • , '" __ .• [}.a~ ·ulll'Jaili&gs: ,,,""_ .•.• __ __ __ " __ •.

OOCJJpa'Uon

Work addresa;

p~ add~ __ '"_._ ........ .... ~ .,·_.li._._~ .. __,. ... , .•• oi .. _~ .. _.r .. r.,IIIII ..... ,.,IIIL

TelflptlDn.e No: ."~--- - COde: ----_.,,

Postal address: . ·._ .... · .... · ·· · .H __ •• __ ~<--_·-.

Telephors N« . Code : _ , --_'" ," .

a. PARlilCUILARS OF TRAVEL

Wllal' is 1nfll pUlf!iOOs ~. ymlr J[)umf!~ (~ MI~l - _. __ ..

o '~Sl

t FblJd T rnI'l

f'rOPOSDrJ dala 1:11 duparturu ...

D MOrilh(s)

See Nr i

_., ••• ·_,'·····",- .. n ..

01 Year{!l)

I r.lI v ~ von ~\ er hCt~ 11 I\;NH Ideod or I ef U~I;J 1!'1Uni h~ N .umjhl,i~ I tn v L;' )Iii U ~ .... ~·I bee n dl!p\ !l1c~l ~ ~r or deted It'

Ie vc t'\~lllllbm'! [Yo. [ 11", .. I

I Iuvc you ever been CuU\'i( l~t.I IJi" lill) erimc Hl ,),11:> ~\Jun\I1' ~ ty(; .. 1 150:

(j /\re yeu ~IIITl:nn!!. [rum [Ublll ~~!JI1~1~. Ilf .my b1tbL'T L·unlligUnJ.~ ILILIY dt~ .. ...:: lr.IdUnIl.a.. cr ilJ:i!!, ~thi:r <:hnuuc ~)"": mti..'"I!Llnn. Ir:lmbcSL:JI, )'<lw:.. scabtcs Or an) other COII11lgl\llJ~ bact znul other skin dLS!! se: sypb.llts or any other "'c[h:rnl uls..::ai'>.t':; In Ie;pm:.» or acquned

immune deficiency !o) ndrome virus (;ml~ \ umt or uu mental JUno.:. or a!11ictinn'l ! \'U;'~l f . !-...!i r 1

J, ~ r the reply ill .[Llty Om:' 1I th~ 41.1!.;'~Wm~ h 11) 19 b in 'Lhl:' J.llirm!llw~. all.ll b luH paruculars

2 L·hrlhc!1Lj l.)ilLC _ 101 Plaee -ommy: _

REPUBLIC' OF· ·.AMIB) M ~NlSTRY OF HOM _ A.F .. IRS D JJ1ARTMENT OF CIVIC AFFAlRS [MMIGRATaON CONTROL ACf. 1993

Al)IPLIC TID fOR V]A

( Sections 12 AN D J ~ I Regulation I f J

Surname:

F ~I']';I Nalll~'.~

" ivlil idt:11 uume j it tlrrhc~ml t~ or wa-.;: a mamed wornon l

Il MS ·1, T( I I () ro :m~ co ,tl'l lTd 1"1 J-J.Y [\,lSI 1l.'Ilt..:'G JL."I ·X·' It" lUI ,'PI'RUI'Rl,\ H nux

Sex [ 1I..hll~ _LI [i1:1Il-lil:! J

" 1\01 ni"J Inl

Sl.I~LlS I ,..,,~W~ \l<IHlru I 1 ~~aml:'(i 1 II~~ [~lila".. '\\ IllLl\~ ~f

IIHVI! )lnU .-11 lUI) 11m!! ~.fl~'licJ j,'r r~tmi' !~, -.enl&:' pcm\!IHcllItly III Nalllllll'l"

['"~I 1I~1'1

[YC1 I 11""'-1 I

J-I/mm

FOR OFFICli\.L USE ONL~' Apprnved I Not. Approved Sing,le I Mliltiple Entry

file No.: _

3, l'ilIZt~[]_lihl[1·

4_ P::L~SrOll: (<Il Number: __ ( ., ~ l),nt:' (}f issue _

~c ~ I~ passport yalid for travel [0 Namibia;

5. ~ It) Presen: resu:lenuaJ adUr:~s!i: __

l iLl\':qll1l\.."'t! by DlIHlrJJi2II1illf1StatC original dtlZ(·mfhlp·~ (11 I PliIC~ of issue.

I J IJate 0 C:I<JlII)·

fv",sO 1_ '0 I I

(b) 1 clrphonc number- ~Cl1dc:: .1 D: _

b. A.Jdrei .... and period at' fl."Sl dence in country of,~ bich ~ 00 arc II pL"J1Tl'm1L·nt resident : _

i(a) Residential address: _

(hf]\::lrrhom: number: (Code. 1 :"oi~l· __

,(q Period: _

7 OC(;UpaUOH (if pm fcs.. .. ion:

8. Finn, company, ll'!i\·ell'lt). etc, ;(1 \\ bien ynu an! mlII1:hed or which you represent _

~II} N ::lin.1C anJ<lddire,~~ or ~'TTipl(lycr:

tb ~ Telephone numb 'r: ~ f't~de; _

_,: u _

(e) ature ol' business: _

((n Ira smdern, name ~hruI1j\'t~lty'lnwhich YOII ,wdtlAKl'tItd andthe course pursued _

9, II' acconrpamcd by JHlf \,,'ir~' lITIU.! cuildren t.lltlC.

FIRS"I NA"'1ES

D"'TF OF R.fRTI I

_____ '.11 b1 !el

tal thl

~t;) _

REPUHLle OF ITBlA

!!IUNIS'fRY OF DO!\'JE J-\fF IRS

DEP' RT;\OC''T,QF crvrc AFFAI.RS AP:PUG\TJONFOR. TE).'IPORJ\R¥' ORK OQ"TI1DYF'ElL\'lrr

)IRECTlVES:

I" This form must he completed 10 Bl OCK Leners.

2. All i~cm5 lnUSl be completed in detail. s\ m~~ d:.'l.~h i not acceptable

3. Failure W ,·oI.H.nplete i'll detatl \lorill c.::m!iC J..1l:u:mces..'W)' delay,

4. The :.('Imp~etcrl form must be ron"'a:rooo to nhr·lJl1der·Secn~IiJ:IJ', Department or Ci .. tc Afri~ hs, rl'iv01te oo~ I nO)" \V:mdhoeJ,. Nalnlbj tI

.PAR'T)CUL ,,;ItS OF THE APPUCANT

Surname:

M"~rnNilln~tlf~rlk~Ncr _

Fir.sl Names (in full): _

Pf.lrw:ubrs of bmh:

lu) Dale nr birth: ~~

~ h f Place L~f birtlr, ----:::-::----::- -,-- .

(Di<.trkl) (COUr1try I

r ,-=£-:I,"-"\-I....[1""T; I ~I

MALF ~

!. Mariud, l>lalw .. IllldkHle by means ul':m "X" whatever 11' apphcable and auach bOP)' 01. marnaue ceni!'l,c,uc)

Slt1gl,1.: c=J Mnrned c=J \Vil1.dow,,~ri.Fldowd[:::::::=J Scpl!r::ltctl CJ Di\>'t1r(,;<.~u c=J "'H scpcrnted .. ~t!~te whether tb\'or~c proceedmgs have beeu instinncd nrul W'ht~11 final Ji\'urLL.: h C'X.PC'L,;iJ.:J:

Idtntily nUJll~~ (irHV~IHh~c)~ ~~ __ ~~~ ~

I, Passport or other travel document:

c:.) Number: tblDmenfc.xpiry _

fL') Issuing Authority (all;,u.:b document) ~ _

(d) N<lt~lJmtl.ily: _

~e} Immigration Perm.i.l ~umber?: In Date ofissiW; _

Particu I ars of r~s i den ce inN arm hI (I j iran y): t h not, eopmlete paragraph I J )

fa,l dare of entry: ~

(hI Posta] aduressin Namibia: . _

Ie) Re s ideruial Address _

_______________________ Telephone Number, _

h;l) If you UTe alreadyworking :\amihia_ nr on a visit, state numberand date of your temporary residence permit

h;)II' you have no permit explain circumstances uruter which you Jim) yourself in Namibia;

10. (a, I r married. state full name of spouse ~inc~udil1~ nun den name. where applicable J: _

t b) P lace and dale or hi rth uf ~ ["II 11.1 'i.e .

(,) Ni:!h1 re ami address of employer of SPOLI~C llf cmploy~d~· ~ ~_

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