Change of Name By Deed Poll intended to be Enrolled in the

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NEW NAME IN FULL:

(Block Letters)

ADDRESS:

(Block Letters)

Change of Name By Deed Poll

OLD NAME IN FULL:

(Block Letters)

CITIZENSHIP:

DATE OF BIRTH:

(Block Letters)

I HEREBY DECLARE

That I wholly renounce, relinquish and abandon the use of my old name and in place thereof do assume and adopt from the date hereof my new name so that I may hereafter be called known and distinguished not by my old name but by my new name,

That I shall at all times hereafter in all records, deeds and documents and any other writing and in all actions, suits and proceedings as well as in all dealings, transactions matters and things whatsoever and upon all occasions use and subscribe my new name in place of and in lieu of my old name relinquished as aforesaid,

That I expressly authorise and request all persons at all times hereafter to designate and address me by my assumed and adopted new name.

In Witness I have subscribed my former name and adopted name this day of 20

Signed as a Deed and delivered

(NEW NAME)

(NEW NAME SIGNATURE) ....................................

(OLD NAME) Formerly known as

(OLD NAME SIGNATURE) .....................................

In the presence of .........................................

(WITNESS SIGNATURE)

(WITNESS NAME) (Block Letters) ..................................

(WITNESS ADDRESS) (Block Letters) ..........................................................................

..........................................................................

..........................................................................

(WITNESS OCCUPATION) (Block Letters) .......................................

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