Fillable Under 6s Gp Visit Card Application Form English (Ireland - Health Service Executive)

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Under 6s Gp Visit Card Application Form English (Ireland - Health Service Executive)

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Country of origin: IRELAND
File type: PDF

Ireland forms for Health Service Executive

BROWSE IRELAND - HEALTH SERVICE EXECUTIVE FORMS

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Application for certificate of Birth/Death/Marriage/Adoption/Civil Partnership
How Do I Apply?
In Person: Complete details below and present at public counter.
By Post: Complete details below and send to Civil Registration Office,
Office of the Registrar General,
Government Offices,
Convent Road,
Roscommon,
Co. Roscommon,
Ireland.
By Fax: Complete details below and fax to +353 906632999.
Section 1: Types and Costs of Certificates
Type
Description
Cost €
Certificate (Long
Form Certificate)
This is a certified copy of an entry in the register and is the
certificate used for legal and administrative purposes.
€20.00
Photocopy
Photocopies of entries in the registers are also available.
Photocopies contain the same information as the certificate
but are only of use for research purposes.
Specified Services
Certificate
Certain Departments/Organisations have legislative
provision to allow for the purchase of certificates at the
reduced price of €1 for certain specified services. These
applications for specified services certificates must be
accompanied by a letter from the relevant
Department/Organisation.
€1.00
Authenticated
This is required in certain circumstances only (in addition to
the certified copy) and is available on request from the Civil
Registration Office, Convent Road, Roscommon, Ireland.
€10.00
Section 2: How Do I Pay?
Cash: Personal applications only please. Only Euro Cash will be accepted.
Cheque: Please note that cheques should be made payable to ‘Civil Registration Service’. Only Euro
cheques drawn on a branch of a bank located in the Republic of Ireland will be accepted.
Credit Card: Maste
rCard and Visa credit cards are accepted.
Debit Card: Lase
r Card and Visa debit cards are accepted.
Section 3: How will I receive my certificate?
Certified copies (certificates) are printed on secure paper and must be posted. If you are purchasing a
photocopy we can e-mail the photocopy to you instead of posting it. Please indicate if you want to have
the photocopy e-mailed to you in Section 4 overleaf.
€4.00
Section 4: Details of person applying for the certificate
Applicant’s
Forename:
Applicant’s
Surname:
Address:
Telephone
No:
E-mail address:
Section 5 : Details of person whose certificate is required
PLEASE COMPLETE ALL FIELDS POSSIBLE (FOR THE CERTIFICATE YOU REQUIRE) SO THE ENTRY CAN BE FOUND
Name of person whose birth certificate is
required:
Date of birth:
Place of birth(if
possible):
Father’s Name:
Mother’s Maiden Name:
(incl. forename)
Tick here if the person
has been legally adopted:
Tick as appropriate: Long Form Certificate Photocopy
Specified Services
Authenticated Certificate
Names and Surnames of the parties:
Date and place of marriage/civil partnership:
Tick as appropriate:
Death Certificate
Name and Surname:
Age of Deceased:
Date of Death:
Place of Death:
Address:
If this application is for a photocopy we can e-mail it to you at the above e-mail address – Tick
here if you wish for it to be emailed to you.
Tick as appropriate:
Long Form Certificate Short Certificate Photocopy Specified Services
Authenticated Certificate
Long Form Certificate Photocopy
Specified Services
Authenticated Certificate
Section 6: Further Details
ALL APPLICATIONS FOR SPECIFIED SERVICES CERTIFICATES MUST BE ACCOMPANIED BY A LETTER FROM THE RELEVANT
OFFICE/AGENCY.
Method of Payment:
Cheque Credit Card Laser/Visa Debit Card
If paying by credit card, please indicate whether: MasterCard Visa
If paying by Credit Card/Debit Card all of the following details must be furnished:
Name of Card Holder (Block Capitals):_____________________________________________________
Credit Card Billing Address:______________________________________________________________
Signature of Card Holder: _______________________
Expiry Date(mm/yyyy):
/
Card Number:
-- -- --
3 Security digits (located on the back of card)
____________________________________________________________________________________________
Official Use DATE STAMP
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Under 6s Gp Visit Card Application Form English (Ireland - Health Service Executive)

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Completed 19 July 2020

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