Application For Birth Affidavit Form printable pdf download

Application For Birth Affidavit Form

Consulate General of Liberia in New York

866 UN Plaza, Suite 249

New York, NY 10017

Application for Birth Affidavit

Photo

For Office use ONLY

Document No: _____________

Date of Issuances: __________

Expiration Date: ___________

Fee(s):____________________

Receipt No: _______________

Last Name _____________________________ First Name ___________________________ MI___ Title____

Previous Name, if any: ________________________________________Telephone #_______________________

Date of Birth__________________________ Gender Male □ Female □

Month/Day/Year

Place of birth: Town_______________ City _____________ County _______________ Country ____________

Present Address_________________________________________________________________

City___________ State_____ Zip Code _________Country_________ Phone #______________

Profession/Occupation to be used in Passport _______________________________________________

How did you obtain Liberian Citizenship? Nature □ Naturalized □

Father’s Last Name _______________________ First Name _______________________ MI ___

Living □ Deceased □

Father’s Country of Origin ____________________Father’s Nationality___________________

Natural □ Naturalized □

Father’s date of Naturalization _____________________________________

Month/ Day/Year

Mother’s Last Name ______________________ First Name _______________________ MI ___

Living □ Deceased □

Mother’s County of Origin __________________ Mother’s Nationality ___________________

Natural □ Naturalized □

Mother’s date of Naturalization __________________________

Month/Day/Year

Name of Next of Kin ____________________________Relationship to Next of Kin __________________

Application For Birth Affidavit Form