No. 41970   51 STAATSKOERANT, 12 OKTOBER 2018 G.P.-S. 09/18 DHA-24/PB REPUBLIC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS Annexure 1A PROOF OF BIRTH PB0000000001 The form must be completed in BLACK INK with BLOCK LETTERS for each child. Hospital/Medical Facility Name Facility Code Nominal Register Number NOTE: If birth occurred at a place other than a Hospital or Medical Facility, specify place of birth and estimated time A. PARTICULARS OF HEALTH PRACTITIONER WHO ATTENDED THE BIRTH Health Facility Stamp Surname Forenames in full HPCSA/SANC Reg no. Telephone no. Cell phone no. Signature Date of birth Y Y Y Y M M M M M M M M M D D (write month in full) B. PARTICULARS OF MOTHER / PARENT A Identity No./Passport No. Citizenship Date of birth Y Y Y Y M M M M M M M M M D D (write month in full) Surname Previous/Maiden Surname Forenames in full Physical address: Street Postal Code Town / Village Province Telephone no. Cell No. E-mail address C. PARTICULARS OF FATHER / PARENT B Identity No./Passport No. Citizenship Date of birth Y Y Y Y M M M M M M M M M D D (write month in full) Surname Forenames in full Physical address: Street Postal Code Town / Village Province Telephone no. Cell No. E-mail address D. PARTICULARS OF CHILD Date of birth Y Y Y Y M M M M M M M M M D D (write month in full) Sex: Surname Forenames in full Place of birth Provide time of birth for each child Child 1 Time Child 2 Time Child 3 Time Child 4 Time Child 5 Time Child 6 Time Signature of Parent * If twins or more, provide time of birth for each child. For each child, complete separate (DHA-24/PB) and submit all forms together. Page 1 of 1 This gazette is also available free online at www.gpwonline.co.za