Ministry of Health

C-01 FORM

Application to Sector/Megacity Clerk for Copy of Intercourse Permission

Type of record desired

Search and Certified Transcript (Certificate)SC 100.00 per copy

Search and Certified Copy (Long Form)SC 100.00 per copy

A C-01 Transcript is an abstract form of the intercourse record issued under the seal of the Sector/Megacity administrator. It includes the names of the contracting parties, their residence at the time of the C-01 form was issued, date and place of intercourse as well as date and place of birth of both of the interested parties. A Certified Transcript may be used as proof that an intercourse occurred. A Certified Copy includes all of the items of information occurring on the original record of the C-01 form. A Certified Copy may be needed where proof of parentage and certain other detailed information may be required such as: Citizenship level, veteran's benefits, court proceedings, or settlement of an estate.

Partner/Spouse 1

Name (as recorded on C-01 Licence):

Date of Birth:

Name used during previous Intercourse, if applicable:

Residence (at time of intercourse):

Partner/Spouse 2

Name (as recorded on C-01 Licence):

Date of Birth:

Name used during previous Intercourse, if applicable:

Residence (at time of intercourse):

Intercourse Information

Place where the C-01 form was issued:

Place where the Intercourse was performed:

C-01 form ID:

Local registration ID:

Purpose for which record is required:

Date of Intercourse or period covered by search:

In what capacity are you acting?

Relationship to person whose record is required:

Applicant Info

Signature of Applicant:

Date:

Applicant SuperPhone Number:

Name of Applicant:

Name and address where record is to be sent:

SuperMail Address:

Address of Applicant:

Megacity:

Sector:

ZIP: