INDEPENDENT STATE OF PAPUA NEW GUINEA
Form 1
Civil Registration Act (Chapter 304) Amended 2014
BIRTH & NATIONAL IDENTITY REGISTRATION FORM
O. For Office Use Only
*Birth Registration:
*National Identity Card Registration:
*Registration Date:
*Province:
*LLG:
*District:
*Ward:
D D - MM - Y Y Y Y
*Registration Point:
*Registration Officer's Name:
A. Child or Applicant's Details:
*NID No:
PLEASE WRITE IN BLOCK LETTERS & FILL UP ALL REQUIRED INFORMATION (*)
*Date of Birth:
Birth Cert ID/NID No:
*Given Name(s):
D D - MM - Y Y Y Y
*Family Name:
(Name at Birth)
Place of Birth:
*Hospital/Village/Town:
*Province:
*LLG:
*District:
*Ward:
*Gender:
□ Male
*Registered As:
□ Female
□ Natural □ Adoption
□ Fostered
(Fill Form 4: Particulars of an Adoption)
Disability:
B. Parents Details:
NID No:
Order of Child:
Type of Birth:
*Registration Type:
□ Live Birth □ Still Birth
□ Single □ Twins □ Triplets □ Quadruplets
*Mobile No:
MOTHER
FATHER
*Given Name(s):
*Family Name:
(Father's Surname)
*Date of Birth:
*Nationality:
*Occupation
*Denomination:
Place of Origin:
*Country:
*Province/State:
*District:
*LLG:
*Ward:
*Village/Town:
*Tribe:
*Clan:
D D - MM - Y Y Y Y
D D - MM - Y Y Y Y
Current Residential Address:
MOTHER
FATHER
*Province:
*District:
*LLG:
*Ward:
*Village/Town:
Parents Marriage Information:
Type of Marriage:
□ Civil
(Civil & Customary Marriage Only)
□ Customary □ Defacto
Date of Marriage:
D D - MM - Y Y Y Y
Marriage Reg. No:
C. National Identity Card Information:
THIS SECTION IS TO BE COMPLETED BY APPLICANTS 18 YEARS AND ABOVE ONLY
*Province:
*LLG:
*District:
*Ward:
*Village/Town:
*Tribe:
Place of Origin:
*Society:
□ Patrilineal
□ Matrilineal
*Clan:
Current Residential Address:
*Province:
*LLG:
*District:
*Ward:
*Village/Town:
*Marital Status:
□ Never Married
Preferred Spouse Family Name:
□ Married □ Separated
□ Divorced
□ Widow/Widower
(Married Woman Only)
Spouse NID No/Name:
*Education:
*Occupation:
□ Never Attended School
□ Elementary □ Primary
□ Secondary □ Tertiary □ Others
*Denomination:
D. Witness Details:
AUTHORIZED WITNESS ONLY - COUNCILLOR, PASTOR, CLAN LEADER, HEALTH WORKER, PROFESSIONALS
*Given Name(s):
NID No:
*Family Name:
Current Residential Address:
*Province:
*LLG:
*District:
*Ward:
*Village/Town:
*Occupation:
*Signature:
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I hereby certify that the above information is correct for the purpose of registration under the Civil Registration Act (Chapter 304) Amended 2014
*Registration Officer's Signature:-------------------------
*Applicant's Signature/Mark:-------------------------