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PEOPLE’S COMMITTEE SOCIALIST REPUBLIC OF VIETNAM Independence - Freedom- Happiness Commune/ward: Form BTP/HT-2006-KS.1a No.: 345 Book no.: 01/2015 District: Province/City: CERTIFICATE OF BIRTH (THE COPY) Full name: Sex: Date of birth: (In words): Place of birth: Ethnic group: Nationality: Native village: Full name of father: Sex: Ethnic group: Nationality: Full name of mother: Sex: Ethnic group: Nationality: Full name of declarant: Relationship with declarant: Civil Status Judicial Officials (Signed) Dated …… …… …… INSTATE PEOPLE’S COMMITTEE PP CHAIRMAN (Signed and sealed) Copy from Birth Registration Book Date … month …… year … PP Chairman