Part 2 particulars to be entered where the record of the birth was created on or after 1st October 1973 and on or before 1st December 1996
| Birth registered in the district of | |
| Child | – Surname |
| – Name | |
| – Sex | |
| – Date of birth | |
| – District of birth | |
| – Place of birth | |
| Father | – Name and surname |
| – Occupation | |
| Mother | – Name and surname |
| – Usual address | |
| – Maiden surname | |
| – Surname at marriage (if different from maiden surname) | |
| Informant | – Qualification |
| – Address | |
| – Signature | |
| Date of registration | |
| Signature of Registrar | |