Fillable ANNOTATION OF BIRTH FACTS ABSTRACTED FROM CERTIFIED COPY (Nicolet Area Technical College)

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ANNOTATION OF BIRTH FACTS ABSTRACTED FROM CERTIFIED COPY (Nicolet Area Technical College)

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Wisconsin Department of Justice
Law Enforcement Standards Board
DJ-LE- 322, Rev. 3/14
www.wilenet.org
ANNOTATION OF BIRTH FACTS ABSTRACTED FROM
CERTIFIED COPY OF BIRTH CERTIFICATE
Name of Training School: Nicolet Area Technical College
It is illegal in the State of Wisconsin to photocopy a vital record and use it as legal proof of birth. The
abstractor should verify the following features of the legal certified copy before accepting it as a legal copy of
the birth certificate:
Check all three before accepting a birth certificate:
Raised Seal of Registrar (not a notary seal on a photocopy)
Signature of Official that Issued Certificate and Date of Issuance
Watermark (chain link that can be seen when held up to the light, issue date 2000 and after)
The following birth facts were abstracted from a certified copy of a birth certificate (with registrar’s raised seal,
signature, date of issuance, and watermark), or other document listed in section 7 of this form, which was
presented to me: Note to Applicant: Complete 1. through 6. only, do not sign the bottom of the form.
1. Student’s Name (First Name)
(Full Middle Name)
(Last Name)
(Title, e.g., Jr.)
2. Date of Birth (Month, Day, Year)
3. Gender
Male Female
4. Name of Mother Listed (First Name)
(Middle Name)
5. Name of Father Listed (First Name)
(Middle Name)
6. Place of Birth
USA or specify:
State
City, Village, Town
County
7. Certified Copy of Birth Certificate Issued by
City
County
State
or
U.S. Passport (non-expired)
U.S. Department of State form FS-240, DS-1350 or FS-545
U.S. Department of Homeland Security form N-550, N-570, N-560 or N-561
8. Date of Issuance
(Month, Day, Year)
Certification Statement:
I affirm that to the best of my knowledge, I accurately abstracted the information listed on this form from a certified copy of a birth
certificate, U.S. Passport, U.S. Department of State form FS-240, DS-1350, FS-545, or U.S. Department of Homeland Security form
N-550, N-570, N-560, or N-561, presented as proof of age and citizenship for the above-listed applicant.
Signature
Date Signed (Month, Day, Year)
Note to Applicant: Bring your Certified Birth Certificate to the Nicolet College Public Safety Office along with
this form . Your Birth Certificate will be returned to you.
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ANNOTATION OF BIRTH FACTS ABSTRACTED FROM CERTIFIED COPY (Nicolet Area Technical College)

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Completed 27 July 2020

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