niing Fee RM PAID vide Tregsury Receipt No.

doted Form K(3)

(Rule 17(A))

To: The Registrar, Resident Native Court,

APPLICATION TO BE IDENTIFIED WITH A NATIVE COMMUNITY

In the matter of section 20(1) of the Native Courts Ordinance, 1992,1 do hereby apply to be identified

with the community and to be subject to the native system of personal law of such

community.

1. P E R S O N A L P A R T I C U L A R S O F A P P L I C A N T

(a) Name:

(b) Identity Card No.:

(c) Age:

(d) Date of Birth:

(e) Place of Birth:

(f) Race:

(g) Citizenship:

(h) Religion: :

(i) Occupation:

(j) Present residential address and period of residence:

(k) Tel No.:

(1) Postal Address:

(m) Previous residential address(es) and period of residence:

(n) Knowledge of native dialects (state whether proficiency is excellent good or poor):

2. P A R T I C U L A R S O F N A T U R A L P A R E N T S / A D O P T I N G P A R E N T S *

(a) Father

(i) Name:

(ii) Identity Card No.:

(iii) Age:

(iv) Date of Birth:

(v) Place of Birth:

(vi) Race:

(vii) Citizenship:

(viii) Religion:

(ix) Occupation:

(x) Present residential address:

(b) Mother

(i) Name:

(ii) Identity Card No.:

(i i i) Age:

(iv) Date of Birth:

(v) Place of Birth:

(vi) Race:

(vii) Citizenship:

(viii) Religion:

(ix) Occupation:

(x) Present residential address:

(If applicant has been adopted, state also the particulars of natural parents, if available).

3. M A R I T A L STATUS ( S I N G L E / M A R R I E D A V I D O W / D I V O R C E D ) * I f married, state: (a) Particulars of spouse of applicant

(i) Name:

(ii) Identity Card No.:

(i i i) Age:

(iv) Date of Birth:

(v) Place of Birth:

(vi) Race:

(vii) Citizenship:

(viii) RQligion: :

(ix) Occupation:

(If applicant has more than one spouse, full particulars thereof must also be supplied in a separate document to be attached to this application).

(b) Names of children (male/female) Date of Birth

(i)

(ii)

(iii)

(iv)

( V )

4. REASONS FOR CLAIMING TO B E IDENTIFIED WITH THE PARTICULAR NATIVE COMMUNITY:

5. DOCUMENTS/INFORMATION TO SUPPORT THIS APPLICATION:

Date: (Signature of Applicant/

• On behalf of the Applicant)

* Delete whichever is inapplicable.

PNMB.Kch. 2011